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_label_list	mrx_tier_type_id	mrx_tier_benefit_type	mrx_tier_drug_type	mrx_tier_includes	mrx_tier_cstshr_struct_type	mrx_tier_locat	mrx_tier_inp_1m_num	mrx_tier_inp_2m_num	mrx_tier_inp_3m_num	mrx_tier_inpp_1m_num	mrx_tier_inpp_2m_num	mrx_tier_inpp_3m_num	mrx_tier_innpp_1m_num	mrx_tier_innpp_2m_num	mrx_tier_innpp_3m_num	mrx_tier_extd_days_yn	mrx_tier_mo_1m_num	mrx_tier_mo_2m_num	mrx_tier_mo_3m_num	mrx_tier_mopp_1m_num	mrx_tier_mopp_2m_num	mrx_tier_mopp_3m_num	mrx_tier_monpp_1m_num	mrx_tier_monpp_2m_num	mrx_tier_monpp_3m_num	mrx_tier_oonp_1m_num	mrx_tier_oonp_othnumn	mrx_tier_ltcp_g_1m	mrx_tier_ltcp_g_os	mrx_tier_ltcp_b_1m	mrx_tier_ltcp_b_os	mrx_tier_inp_copay_daily	mrx_tier_inp_copay_1m	mrx_tier_inp_copay_2m	mrx_tier_inp_copay_3m	mrx_tier_inp_coins_avg_1m	mrx_tier_inp_coins_1m	mrx_tier_inp_coins_2m	mrx_tier_inp_coins_3m	mrx_tier_inpp_copay_daily	mrx_tier_inpp_copay_1m	mrx_tier_inpp_copay_2m	mrx_tier_inpp_copay_3m	mrx_tier_inpp_coins_avg_1m	mrx_tier_inpp_coins_1m	mrx_tier_inpp_coins_2m	mrx_tier_inpp_coins_3m	mrx_tier_innpp_copay_daily	mrx_tier_innpp_copay_1m	mrx_tier_innpp_copay_2m	mrx_tier_innpp_copay_3m	mrx_tier_innpp_coins_avg_1m	mrx_tier_innpp_coins_1m	mrx_tier_innpp_coins_2m	mrx_tier_innpp_coins_3m	mrx_tier_mo_copay_daily	mrx_tier_mo_copay_1m	mrx_tier_mo_copay_2m	mrx_tier_mo_copay_3m	mrx_tier_mo_coins_1m	mrx_tier_mo_coins_2m	mrx_tier_mo_coins_3m	mrx_tier_mopp_copay_daily	mrx_tier_mopp_copay_1m	mrx_tier_mopp_copay_2m	mrx_tier_mopp_copay_3m	mrx_tier_mopp_coins_1m	mrx_tier_mopp_coins_2m	mrx_tier_mopp_coins_3m	mrx_tier_monpp_copay_daily	mrx_tier_monpp_copay_1m	mrx_tier_monpp_copay_2m	mrx_tier_monpp_copay_3m	mrx_tier_monpp_coins_1m	mrx_tier_monpp_coins_2m	mrx_tier_monpp_coins_3m	mrx_tier_oonp_copay_1m	mrx_tier_oonp_copay_othnum	mrx_tier_oonp_coins_1m	mrx_tier_oonp_coins_othnum	mrx_tier_ltcp_copay_g_daily	mrx_tier_ltcp_copay_g_1m	mrx_tier_ltcp_coins_g_1m	mrx_tier_ltcp_copay_b_daily	mrx_tier_ltcp_copay_b_1m	mrx_tier_ltcp_coins_b_1m	mrx_tier_gap_cost_share	mrx_tier_gap_part_drugs	mrx_tier_gap_part_includes
H0028	001	0	1	01	01	H0028_001_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H0028	001	0	1	01	01	H0028_001_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H0028	001	0	1	01	01	H0028_001_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H0028	001	0	1	01	01	H0028_001_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H0028	001	0	1	01	01	H0028_001_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					856.00	33																														33							33					33				33			33	2	3	
H0028	001	0	1	01	01	H0028_001_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00		2	3	1
H0028	001	0	1	01	01	H0028_001_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H0028	001	0	1	01	01	H0028_001_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H0028	001	0	1	01	01	H0028_001_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H0028	001	0	1	01	01	H0028_001_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					745.00	33																														33							33					33				33			33			
H0028	002	0	1	01	01	H0028_002_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H0028	002	0	1	01	01	H0028_002_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					872.00	33																														33							33					33				33			33	2	3	
H0028	002	0	1	01	01	H0028_002_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H0028	002	0	1	01	01	H0028_002_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H0028	002	0	1	01	01	H0028_002_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H0028	002	0	1	01	01	H0028_002_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					761.00	33																														33							33					33				33			33			
H0028	002	0	1	01	01	H0028_002_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H0028	002	0	1	01	01	H0028_002_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H0028	002	0	1	01	01	H0028_002_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H0028	002	0	1	01	01	H0028_002_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H0028	003	0	1	01	01	H0028_003_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H0028	003	0	1	01	01	H0028_003_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H0028	003	0	1	01	01	H0028_003_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					892.00	33																														33							33					33				33			33	2	3	
H0028	003	0	1	01	01	H0028_003_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H0028	003	0	1	01	01	H0028_003_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H0028	003	0	1	01	01	H0028_003_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H0028	003	0	1	01	01	H0028_003_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00		2	3	1
H0028	003	0	1	01	01	H0028_003_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					780.00	33																														33							33					33				33			33			
H0028	003	0	1	01	01	H0028_003_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H0028	003	0	1	01	01	H0028_003_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H0028	004	0	1	01	01	H0028_004_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					929.00	33																														33							33					33				33			33	2	3	
H0028	004	0	1	01	01	H0028_004_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H0028	004	0	1	01	01	H0028_004_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H0028	004	0	1	01	01	H0028_004_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H0028	004	0	1	01	01	H0028_004_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H0028	004	0	1	01	01	H0028_004_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	1
H0028	004	0	1	01	01	H0028_004_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H0028	004	0	1	01	01	H0028_004_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H0028	004	0	1	01	01	H0028_004_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H0028	004	0	1	01	01	H0028_004_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					788.00	33																														33							33					33				33			33			
H0084	001	0	1	04	01	H0084_001_0	6	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					824.00	33	33	33																					33	33	33																	33				33			33			
H0084	001	0	1	04	01	H0084_001_0	6	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
H0084	001	0	1	04	01	H0084_001_0	6	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
H0084	001	0	1	04	01	H0084_001_0	6	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					6.00	12.00	18.00																						6.00	12.00	15.00																		6.00					6.00							
H0084	004	0	1	04	01	H0084_004_0	4	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
H0084	004	0	1	04	01	H0084_004_0	4	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					910.00	33	33	33																					33	33	33																	33				33			33			
H0084	004	0	1	04	01	H0084_004_0	4	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					6.00	12.00	18.00																						6.00	12.00	15.00																		6.00					6.00							
H0084	004	0	1	04	01	H0084_004_0	4	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
H0084	007	0	1	04	01	H0084_007_0	4	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
H0084	007	0	1	04	01	H0084_007_0	4	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
H0084	007	0	1	04	01	H0084_007_0	4	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					8.00	16.00	24.00																						8.00	16.00	20.00																		8.00					8.00							
H0084	007	0	1	04	01	H0084_007_0	4	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					892.00	33	33	33																					33	33	33																	33				33			33			
H0084	009	0	1	04	01	H0084_009_0	4	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					10.00	20.00	30.00																						10.00	20.00	25.00																		10.00					10.00							
H0084	009	0	1	04	01	H0084_009_0	4	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					843.00	33	33	33																					33	33	33																	33				33			33			
H0084	009	0	1	04	01	H0084_009_0	4	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
H0084	009	0	1	04	01	H0084_009_0	4	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
H0084	011	0	1	04	01	H0084_011_0	4	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					882.00	33	33	33																					33	33	33																	33				33			33			
H0084	011	0	1	04	01	H0084_011_0	4	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
H0084	011	0	1	04	01	H0084_011_0	4	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					8.00	16.00	24.00																						8.00	16.00	20.00																		8.00					8.00							
H0084	011	0	1	04	01	H0084_011_0	4	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
H0084	013	0	1	04	01	H0084_013_0	4	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					822.00	33	33	33																					33	33	33																	33				33			33			
H0084	013	0	1	04	01	H0084_013_0	4	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
H0084	013	0	1	04	01	H0084_013_0	4	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
H0084	013	0	1	04	01	H0084_013_0	4	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					9.00	18.00	27.00																						9.00	18.00	22.50																		9.00					9.00							
H0084	015	0	1	04	01	H0084_015_0	4	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
H0084	015	0	1	04	01	H0084_015_0	4	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
H0084	015	0	1	04	01	H0084_015_0	4	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					8.00	16.00	24.00																						8.00	16.00	20.00																		8.00					8.00							
H0084	015	0	1	04	01	H0084_015_0	4	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					896.00	33	33	33																					33	33	33																	33				33			33			
H0084	017	0	1	04	01	H0084_017_0	4	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					10.00	20.00	30.00																						10.00	20.00	25.00																		10.00					10.00							
H0084	017	0	1	04	01	H0084_017_0	4	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
H0084	017	0	1	04	01	H0084_017_0	4	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
H0084	017	0	1	04	01	H0084_017_0	4	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					852.00	33	33	33																					33	33	33																	33				33			33			
H0084	019	0	1	04	01	H0084_019_0	4	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
H0084	019	0	1	04	01	H0084_019_0	4	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
H0084	019	0	1	04	01	H0084_019_0	4	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					8.00	16.00	24.00																						8.00	16.00	20.00																		8.00					8.00							
H0084	019	0	1	04	01	H0084_019_0	4	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					899.00	33	33	33																					33	33	33																	33				33			33			
H0084	021	0	1	04	01	H0084_021_0	4	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					851.00	33	33	33																					33	33	33																	33				33			33			
H0084	021	0	1	04	01	H0084_021_0	4	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					10.00	20.00	30.00																						10.00	20.00	25.00																		10.00					10.00							
H0084	021	0	1	04	01	H0084_021_0	4	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
H0084	021	0	1	04	01	H0084_021_0	4	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
H0084	023	0	1	04	01	H0084_023_0	4	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					6.00	12.00	18.00																						6.00	12.00	15.00																		6.00					6.00							
H0084	023	0	1	04	01	H0084_023_0	4	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
H0084	023	0	1	04	01	H0084_023_0	4	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					917.00	33	33	33																					33	33	33																	33				33			33			
H0084	023	0	1	04	01	H0084_023_0	4	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
H0084	027	0	1	04	01	H0084_027_0	4	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					888.00	33	33	33																					33	33	33																	33				33			33			
H0084	027	0	1	04	01	H0084_027_0	4	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
H0084	027	0	1	04	01	H0084_027_0	4	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
H0084	027	0	1	04	01	H0084_027_0	4	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					6.00	12.00	18.00																						6.00	12.00	15.00																		6.00					6.00							
H0084	030	0	1	04	01	H0084_030_0	4	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					8.00	16.00	24.00																						8.00	16.00	20.00																		8.00					8.00							
H0084	030	0	1	04	01	H0084_030_0	4	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
H0084	030	0	1	04	01	H0084_030_0	4	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
H0084	030	0	1	04	01	H0084_030_0	4	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					871.00	33	33	33																					33	33	33																	33				33			33			
H0084	032	0	1	04	01	H0084_032_0	4	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
H0084	032	0	1	04	01	H0084_032_0	4	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					8.00	16.00	24.00																						8.00	16.00	20.00																		8.00					8.00							
H0084	032	0	1	04	01	H0084_032_0	4	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					861.00	33	33	33																					33	33	33																	33				33			33			
H0084	032	0	1	04	01	H0084_032_0	4	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
H0084	034	0	1	04	01	H0084_034_0	4	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					8.00	16.00	24.00																						8.00	16.00	20.00																		8.00					8.00							
H0084	034	0	1	04	01	H0084_034_0	4	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
H0084	034	0	1	04	01	H0084_034_0	4	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
H0084	034	0	1	04	01	H0084_034_0	4	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					875.00	33	33	33																					33	33	33																	33				33			33			
H0084	037	0	1	04	01	H0084_037_0	4	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					8.00	16.00	24.00																						8.00	16.00	20.00																		8.00					8.00							
H0084	037	0	1	04	01	H0084_037_0	4	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					879.00	33	33	33																					33	33	33																	33				33			33			
H0084	037	0	1	04	01	H0084_037_0	4	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
H0084	037	0	1	04	01	H0084_037_0	4	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
H0084	040	0	1	04	01	H0084_040_0	4	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
H0084	040	0	1	04	01	H0084_040_0	4	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
H0084	040	0	1	04	01	H0084_040_0	4	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					6.00	12.00	18.00																						6.00	12.00	15.00																		6.00					6.00							
H0084	040	0	1	04	01	H0084_040_0	4	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					893.00	33	33	33																					33	33	33																	33				33			33			
H0084	042	0	1	04	01	H0084_042_0	4	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					8.00	16.00	24.00																						8.00	16.00	20.00																		8.00					8.00							
H0084	042	0	1	04	01	H0084_042_0	4	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					886.00	33	33	33																					33	33	33																	33				33			33			
H0084	042	0	1	04	01	H0084_042_0	4	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
H0084	042	0	1	04	01	H0084_042_0	4	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
H0084	044	0	1	04	01	H0084_044_0	4	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					865.00	33	33	33																					33	33	33																	33				33			33			
H0084	044	0	1	04	01	H0084_044_0	4	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
H0084	044	0	1	04	01	H0084_044_0	4	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					8.00	16.00	24.00																						8.00	16.00	20.00																		8.00					8.00							
H0084	044	0	1	04	01	H0084_044_0	4	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
H0084	046	0	1	04	01	H0084_046_0	4	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
H0084	046	0	1	04	01	H0084_046_0	4	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					831.00	33	33	33																					33	33	33																	33				33			33			
H0084	046	0	1	04	01	H0084_046_0	4	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
H0084	046	0	1	04	01	H0084_046_0	4	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					10.00	20.00	30.00																						10.00	20.00	25.00																		10.00					10.00							
H0084	048	0	1	04	01	H0084_048_0	4	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					8.00	16.00	24.00																						8.00	16.00	20.00																		8.00					8.00							
H0084	048	0	1	04	01	H0084_048_0	4	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
H0084	048	0	1	04	01	H0084_048_0	4	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
H0084	048	0	1	04	01	H0084_048_0	4	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					898.00	33	33	33																					33	33	33																	33				33			33			
H0084	050	0	1	04	01	H0084_050_0	4	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
H0084	050	0	1	04	01	H0084_050_0	4	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
H0084	050	0	1	04	01	H0084_050_0	4	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					8.00	16.00	24.00																						8.00	16.00	20.00																		8.00					8.00							
H0084	050	0	1	04	01	H0084_050_0	4	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					877.00	33	33	33																					33	33	33																	33				33			33			
H0084	052	0	1	04	01	H0084_052_0	4	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					10.00	20.00	30.00																						10.00	20.00	25.00																		10.00					10.00							
H0084	052	0	1	04	01	H0084_052_0	4	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
H0084	052	0	1	04	01	H0084_052_0	4	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					855.00	33	33	33																					33	33	33																	33				33			33			
H0084	052	0	1	04	01	H0084_052_0	4	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
H0084	054	0	1	04	01	H0084_054_0	4	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					8.00	16.00	24.00																						8.00	16.00	20.00																		8.00					8.00							
H0084	054	0	1	04	01	H0084_054_0	4	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
H0084	054	0	1	04	01	H0084_054_0	4	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
H0084	054	0	1	04	01	H0084_054_0	4	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					871.00	33	33	33																					33	33	33																	33				33			33			
H0084	056	0	1	04	01	H0084_056_0	4	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
H0084	056	0	1	04	01	H0084_056_0	4	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
H0084	056	0	1	04	01	H0084_056_0	4	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					8.00	16.00	24.00																						8.00	16.00	20.00																		8.00					8.00							
H0084	056	0	1	04	01	H0084_056_0	4	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					851.00	33	33	33																					33	33	33																	33				33			33			
H0084	057	0	1	04	01	H0084_057_0	4	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					10.00	20.00	30.00																						10.00	20.00	25.00																		10.00					10.00							
H0084	057	0	1	04	01	H0084_057_0	4	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
H0084	057	0	1	04	01	H0084_057_0	4	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
H0084	057	0	1	04	01	H0084_057_0	4	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					802.00	33	33	33																					33	33	33																	33				33			33			
H0084	059	0	1	04	01	H0084_059_0	4	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					8.00	16.00	24.00																						8.00	16.00	20.00																		8.00					8.00							
H0084	059	0	1	04	01	H0084_059_0	4	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
H0084	059	0	1	04	01	H0084_059_0	4	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
H0084	059	0	1	04	01	H0084_059_0	4	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					904.00	33	33	33																					33	33	33																	33				33			33			
H0084	061	0	1	04	01	H0084_061_0	4	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					8.00	16.00	24.00																						8.00	16.00	20.00																		8.00					8.00							
H0084	061	0	1	04	01	H0084_061_0	4	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
H0084	061	0	1	04	01	H0084_061_0	4	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
H0084	061	0	1	04	01	H0084_061_0	4	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					883.00	33	33	33																					33	33	33																	33				33			33			
H0084	063	0	1	04	01	H0084_063_0	4	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					864.00	33	33	33																					33	33	33																	33				33			33			
H0084	063	0	1	04	01	H0084_063_0	4	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
H0084	063	0	1	04	01	H0084_063_0	4	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					10.00	20.00	30.00																						10.00	20.00	25.00																		10.00					10.00							
H0084	063	0	1	04	01	H0084_063_0	4	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
H0084	064	0	1	04	01	H0084_064_0	4	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		80.00	160.00	240.00																						80.00	160.00	200.00																		80.00								80.00				
H0084	064	0	1	04	01	H0084_064_0	4	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					862.00	33	33	33																					33	33	33																	33				33			33			
H0084	064	0	1	04	01	H0084_064_0	4	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		40.00	80.00	120.00																						40.00	80.00	100.00																		40.00								40.00				
H0084	064	0	1	04	01	H0084_064_0	4	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					4.00	8.00	12.00																						4.00	8.00	10.00																		4.00					4.00							
H0084	065	0	1	04	01	H0084_065_0	4	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		80.00	160.00	240.00																						80.00	160.00	200.00																		80.00								80.00				
H0084	065	0	1	04	01	H0084_065_0	4	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		40.00	80.00	120.00																						40.00	80.00	100.00																		40.00								40.00				
H0084	065	0	1	04	01	H0084_065_0	4	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					4.00	8.00	12.00																						4.00	8.00	10.00																		4.00					4.00							
H0084	065	0	1	04	01	H0084_065_0	4	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					906.00	33	33	33																					33	33	33																	33				33			33			
H0084	066	0	1	04	01	H0084_066_0	4	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					886.00	33	33	33																					33	33	33																	33				33			33			
H0084	066	0	1	04	01	H0084_066_0	4	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		80.00	160.00	240.00																						80.00	160.00	200.00																		80.00								80.00				
H0084	066	0	1	04	01	H0084_066_0	4	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					4.00	8.00	12.00																						4.00	8.00	10.00																		4.00					4.00							
H0084	066	0	1	04	01	H0084_066_0	4	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		40.00	80.00	120.00																						40.00	80.00	100.00																		40.00								40.00				
H0104	010	1	1	04	01	H0104_010_1	12	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				30		90	30		90	1	30		90							30		31													4.00		8.00						4.00		12.00						4.00		8.00																		4.00					4.00							
H0104	010	1	1	04	01	H0104_010_1	12	2	Non-Preferred Generic	1	4	000100	1	2	000010110110101000000100				30		90	30		90	1	30		90							30		31													12.00		24.00						12.00		36.00						12.00		24.00																		12.00					12.00							
H0104	010	1	1	04	01	H0104_010_1	12	3	Preferred Brand	1	4	000001	1	2	100010110110101000000001				30		90	30		90	1	30		90							30				31	14										45.00		90.00						45.00		135.00						45.00		90.00																		45.00								45.00				
H0104	010	1	1	04	01	H0104_010_1	12	4	Non-Preferred Brand	1	4	100000	1	2	100010110110101000000001				30		90	30		90	1	30		90							30				31	14										75.00		150.00						75.00		225.00						75.00		150.00																		75.00								75.00				
H0104	010	1	1	04	01	H0104_010_1	12	5	Specialty Tier	1	4	010010	1	1	100010110110101000000101				30		90	30		90	1	30		90							30		31		31	14													676.27	33		33					676.27	33		33					33		33																	33				33			33			
H0104	010	2	1	04	01	H0104_010_2	12	5	Specialty Tier	1	4	010010	1	1	100010110110101000000101				30		90	30		90	1	30		90							30		31		31	14													676.27	33		33					676.27	33		33					33		33																	33				33			33			
H0104	010	2	1	04	01	H0104_010_2	12	4	Non-Preferred Brand	1	4	100000	1	2	100010110110101000000001				30		90	30		90	1	30		90							30				31	14										75.00		150.00						75.00		225.00						75.00		150.00																		75.00								75.00				
H0104	010	2	1	04	01	H0104_010_2	12	3	Preferred Brand	1	4	000001	1	2	100010110110101000000001				30		90	30		90	1	30		90							30				31	14										45.00		90.00						45.00		135.00						45.00		90.00																		45.00								45.00				
H0104	010	2	1	04	01	H0104_010_2	12	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				30		90	30		90	1	30		90							30		31													4.00		8.00						4.00		12.00						4.00		8.00																		4.00					4.00							
H0104	010	2	1	04	01	H0104_010_2	12	2	Non-Preferred Generic	1	4	000100	1	2	000010110110101000000100				30		90	30		90	1	30		90							30		31													12.00		24.00						12.00		36.00						12.00		24.00																		12.00					12.00							
H0104	010	3	1	04	01	H0104_010_3	10	4	Non-Preferred Brand	1	4	100000	1	2	100010110110101000000001				30		90	30		90	1	30		90							30				31	14										75.00		150.00						75.00		225.00						75.00		150.00																		75.00								75.00				
H0104	010	3	1	04	01	H0104_010_3	10	3	Preferred Brand	1	4	000001	1	2	100010110110101000000001				30		90	30		90	1	30		90							30				31	14										45.00		90.00						45.00		135.00						45.00		90.00																		45.00								45.00				
H0104	010	3	1	04	01	H0104_010_3	10	2	Non-Preferred Generic	1	4	000100	1	2	000010110110101000000100				30		90	30		90	1	30		90							30		31													12.00		24.00						12.00		36.00						12.00		24.00																		12.00					12.00							
H0104	010	3	1	04	01	H0104_010_3	10	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				30		90	30		90	1	30		90							30		31													4.00		8.00						4.00		12.00						4.00		8.00																		4.00					4.00							
H0104	010	3	1	04	01	H0104_010_3	10	5	Specialty Tier	1	4	010010	1	1	100010110110101000000101				30		90	30		90	1	30		90							30		31		31	14													676.27	33		33					676.27	33		33					33		33																	33				33			33			
H0104	010	4	1	04	01	H0104_010_4	11	4	Non-Preferred Brand	1	4	100000	1	2	100010110110101000000001				30		90	30		90	1	30		90							30				31	14										75.00		150.00						75.00		225.00						75.00		150.00																		75.00								75.00				
H0104	010	4	1	04	01	H0104_010_4	11	3	Preferred Brand	1	4	000001	1	2	100010110110101000000001				30		90	30		90	1	30		90							30				31	14										45.00		90.00						45.00		135.00						45.00		90.00																		45.00								45.00				
H0104	010	4	1	04	01	H0104_010_4	11	2	Non-Preferred Generic	1	4	000100	1	2	000010110110101000000100				30		90	30		90	1	30		90							30		31													12.00		24.00						12.00		36.00						12.00		24.00																		12.00					12.00							
H0104	010	4	1	04	01	H0104_010_4	11	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				30		90	30		90	1	30		90							30		31													4.00		8.00						4.00		12.00						4.00		8.00																		4.00					4.00							
H0104	010	4	1	04	01	H0104_010_4	11	5	Specialty Tier	1	4	010010	1	1	100010110110101000000101				30		90	30		90	1	30		90							30		31		31	14													676.27	33		33					676.27	33		33					33		33																	33				33			33			
H0104	010	5	1	04	01	H0104_010_5	10	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				30		90	30		90	1	30		90							30		31													4.00		8.00						4.00		12.00						4.00		8.00																		4.00					4.00							
H0104	010	5	1	04	01	H0104_010_5	10	2	Non-Preferred Generic	1	4	000100	1	2	000010110110101000000100				30		90	30		90	1	30		90							30		31													12.00		24.00						12.00		36.00						12.00		24.00																		12.00					12.00							
H0104	010	5	1	04	01	H0104_010_5	10	3	Preferred Brand	1	4	000001	1	2	100010110110101000000001				30		90	30		90	1	30		90							30				31	14										45.00		90.00						45.00		135.00						45.00		90.00																		45.00								45.00				
H0104	010	5	1	04	01	H0104_010_5	10	4	Non-Preferred Brand	1	4	100000	1	2	100010110110101000000001				30		90	30		90	1	30		90							30				31	14										75.00		150.00						75.00		225.00						75.00		150.00																		75.00								75.00				
H0104	010	5	1	04	01	H0104_010_5	10	5	Specialty Tier	1	4	010010	1	1	100010110110101000000101				30		90	30		90	1	30		90							30		31		31	14													676.27	33		33					676.27	33		33					33		33																	33				33			33			
H0104	011	1	1	04	01	H0104_011_1	10	1	Preferred Generic	1	3	001000		2	000010110110101000000100				30		90	30		90	1	30		90							30		31													4.00		8.00						4.00		12.00						4.00		8.00																		4.00					4.00							
H0104	011	1	1	04	01	H0104_011_1	10	2	Non-Preferred Generic	1	3	000100		2	000010110110101000000100				30		90	30		90	1	30		90							30		31													10.00		20.00						10.00		30.00						10.00		20.00																		10.00					10.00							
H0104	011	1	1	04	01	H0104_011_1	10	3	Preferred Brand	1	3	000001		2	100010110110101000000001				30		90	30		90	1	30		90							30				31	14										45.00		90.00						45.00		135.00						45.00		90.00																		45.00								45.00				
H0104	011	1	1	04	01	H0104_011_1	10	4	Non-Preferred Brand	1	3	100000		2	100010110110101000000001				30		90	30		90	1	30		90							30				31	14										95.00		190.00						95.00		285.00						95.00		190.00																		95.00								95.00				
H0104	011	1	1	04	01	H0104_011_1	10	5	Specialty Tier	1	3	010010		1	100010110110101000000101				30		90	30		90	1	30		90							30		31		31	14													597.86	25		25					597.86	25		25					25		25																	25				25			25			
H0104	011	2	1	04	01	H0104_011_2	9	5	Specialty Tier	1	3	010010		1	100010110110101000000101				30		90	30		90	1	30		90							30		31		31	14													597.86	25		25					597.86	25		25					25		25																	25				25			25			
H0104	011	2	1	04	01	H0104_011_2	9	4	Non-Preferred Brand	1	3	100000		2	100010110110101000000001				30		90	30		90	1	30		90							30				31	14										95.00		190.00						95.00		285.00						95.00		190.00																		95.00								95.00				
H0104	011	2	1	04	01	H0104_011_2	9	3	Preferred Brand	1	3	000001		2	100010110110101000000001				30		90	30		90	1	30		90							30				31	14										45.00		90.00						45.00		135.00						45.00		90.00																		45.00								45.00				
H0104	011	2	1	04	01	H0104_011_2	9	2	Non-Preferred Generic	1	3	000100		2	000010110110101000000100				30		90	30		90	1	30		90							30		31													10.00		20.00						10.00		30.00						10.00		20.00																		10.00					10.00							
H0104	011	2	1	04	01	H0104_011_2	9	1	Preferred Generic	1	3	001000		2	000010110110101000000100				30		90	30		90	1	30		90							30		31													4.00		8.00						4.00		12.00						4.00		8.00																		4.00					4.00							
H0104	011	3	1	04	01	H0104_011_3	12	4	Non-Preferred Brand	1	3	100000		2	100010110110101000000001				30		90	30		90	1	30		90							30				31	14										95.00		190.00						95.00		285.00						95.00		190.00																		95.00								95.00				
H0104	011	3	1	04	01	H0104_011_3	12	5	Specialty Tier	1	3	010010		1	100010110110101000000101				30		90	30		90	1	30		90							30		31		31	14													597.86	25		25					597.86	25		25					25		25																	25				25			25			
H0104	011	3	1	04	01	H0104_011_3	12	3	Preferred Brand	1	3	000001		2	100010110110101000000001				30		90	30		90	1	30		90							30				31	14										45.00		90.00						45.00		135.00						45.00		90.00																		45.00								45.00				
H0104	011	3	1	04	01	H0104_011_3	12	2	Non-Preferred Generic	1	3	000100		2	000010110110101000000100				30		90	30		90	1	30		90							30		31													10.00		20.00						10.00		30.00						10.00		20.00																		10.00					10.00							
H0104	011	3	1	04	01	H0104_011_3	12	1	Preferred Generic	1	3	001000		2	000010110110101000000100				30		90	30		90	1	30		90							30		31													4.00		8.00						4.00		12.00						4.00		8.00																		4.00					4.00							
H0104	011	4	1	04	01	H0104_011_4	9	4	Non-Preferred Brand	1	3	100000		2	100010110110101000000001				30		90	30		90	1	30		90							30				31	14										95.00		190.00						95.00		285.00						95.00		190.00																		95.00								95.00				
H0104	011	4	1	04	01	H0104_011_4	9	5	Specialty Tier	1	3	010010		1	100010110110101000000101				30		90	30		90	1	30		90							30		31		31	14													597.86	25		25					597.86	25		25					25		25																	25				25			25			
H0104	011	4	1	04	01	H0104_011_4	9	1	Preferred Generic	1	3	001000		2	000010110110101000000100				30		90	30		90	1	30		90							30		31													4.00		8.00						4.00		12.00						4.00		8.00																		4.00					4.00							
H0104	011	4	1	04	01	H0104_011_4	9	2	Non-Preferred Generic	1	3	000100		2	000010110110101000000100				30		90	30		90	1	30		90							30		31													10.00		20.00						10.00		30.00						10.00		20.00																		10.00					10.00							
H0104	011	4	1	04	01	H0104_011_4	9	3	Preferred Brand	1	3	000001		2	100010110110101000000001				30		90	30		90	1	30		90							30				31	14										45.00		90.00						45.00		135.00						45.00		90.00																		45.00								45.00				
H0104	011	5	1	04	01	H0104_011_5	9	4	Non-Preferred Brand	1	3	100000		2	100010110110101000000001				30		90	30		90	1	30		90							30				31	14										95.00		190.00						95.00		285.00						95.00		190.00																		95.00								95.00				
H0104	011	5	1	04	01	H0104_011_5	9	3	Preferred Brand	1	3	000001		2	100010110110101000000001				30		90	30		90	1	30		90							30				31	14										45.00		90.00						45.00		135.00						45.00		90.00																		45.00								45.00				
H0104	011	5	1	04	01	H0104_011_5	9	2	Non-Preferred Generic	1	3	000100		2	000010110110101000000100				30		90	30		90	1	30		90							30		31													10.00		20.00						10.00		30.00						10.00		20.00																		10.00					10.00							
H0104	011	5	1	04	01	H0104_011_5	9	5	Specialty Tier	1	3	010010		1	100010110110101000000101				30		90	30		90	1	30		90							30		31		31	14													597.86	25		25					597.86	25		25					25		25																	25				25			25			
H0104	011	5	1	04	01	H0104_011_5	9	1	Preferred Generic	1	3	001000		2	000010110110101000000100				30		90	30		90	1	30		90							30		31													4.00		8.00						4.00		12.00						4.00		8.00																		4.00					4.00							
H0104	011	6	1	04	01	H0104_011_6	10	2	Non-Preferred Generic	1	3	000100		2	000010110110101000000100				30		90	30		90	1	30		90							30		31													10.00		20.00						10.00		30.00						10.00		20.00																		10.00					10.00							
H0104	011	6	1	04	01	H0104_011_6	10	3	Preferred Brand	1	3	000001		2	100010110110101000000001				30		90	30		90	1	30		90							30				31	14										45.00		90.00						45.00		135.00						45.00		90.00																		45.00								45.00				
H0104	011	6	1	04	01	H0104_011_6	10	4	Non-Preferred Brand	1	3	100000		2	100010110110101000000001				30		90	30		90	1	30		90							30				31	14										95.00		190.00						95.00		285.00						95.00		190.00																		95.00								95.00				
H0104	011	6	1	04	01	H0104_011_6	10	5	Specialty Tier	1	3	010010		1	100010110110101000000101				30		90	30		90	1	30		90							30		31		31	14													597.86	25		25					597.86	25		25					25		25																	25				25			25			
H0104	011	6	1	04	01	H0104_011_6	10	1	Preferred Generic	1	3	001000		2	000010110110101000000100				30		90	30		90	1	30		90							30		31													4.00		8.00						4.00		12.00						4.00		8.00																		4.00					4.00							
H0108	004	0	1	01	01	H0108_004_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H0108	004	0	1	01	01	H0108_004_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H0108	004	0	1	01	01	H0108_004_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H0108	004	0	1	01	01	H0108_004_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					589.00	33																														33							33					33				33			33			
H0108	004	0	1	01	01	H0108_004_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H0108	004	0	1	01	01	H0108_004_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		1		
H0108	004	0	1	01	01	H0108_004_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H0108	004	0	1	01	01	H0108_004_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H0108	004	0	1	01	01	H0108_004_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					698.00	33																														33							33					33				33			33	2	3	
H0108	004	0	1	01	01	H0108_004_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H0108	005	0	1	01	01	H0108_005_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H0108	005	0	1	01	01	H0108_005_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H0108	005	0	1	01	01	H0108_005_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		41.00		123.00																													41.00		113.00					41.00		123.00				41.00					41.00			41.00				
H0108	005	0	1	01	01	H0108_005_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		92.00		276.00																													92.00		266.00					92.00		276.00				92.00					92.00			92.00				
H0108	005	0	1	01	01	H0108_005_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					658.00	33																														33							33					33				33			33			
H0108	005	0	1	01	01	H0108_005_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H0108	005	0	1	01	01	H0108_005_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		1		
H0108	005	0	1	01	01	H0108_005_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		41.00		123.00																													41.00		113.00					41.00		123.00				41.00					41.00			41.00		2	2	
H0108	005	0	1	01	01	H0108_005_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		92.00		276.00																													92.00		266.00					92.00		276.00				92.00					92.00			92.00		2	3	
H0108	005	0	1	01	01	H0108_005_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					755.00	33																														33							33					33				33			33	2	3	
H0108	006	0	1	02	01	H0108_006_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1021.00	33																														33							33					33				33			33	2	3	
H0108	006	0	1	02	01	H0108_006_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H0108	006	0	1	02	01	H0108_006_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H0108	006	0	1	02	01	H0108_006_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H0108	006	0	1	02	01	H0108_006_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	1
H0108	006	0	1	02	01	H0108_006_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					784.00	33																														33							33					33				33			33			
H0108	006	0	1	02	01	H0108_006_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H0108	006	0	1	02	01	H0108_006_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H0108	006	0	1	02	01	H0108_006_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H0108	006	0	1	02	01	H0108_006_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H0108	008	0	1	01	01	H0108_008_0	4	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					585.00	33																														33							33					33				33			33	2	3	
H0108	008	0	1	01	01	H0108_008_0	4	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H0108	008	0	1	01	01	H0108_008_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H0108	008	0	1	01	01	H0108_008_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H0108	008	0	1	01	01	H0108_008_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H0108	008	0	1	01	01	H0108_008_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H0108	008	0	1	01	01	H0108_008_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					480.00	33																														33							33					33				33			33			
H0108	008	0	1	01	01	H0108_008_0	4	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H0108	008	0	1	01	01	H0108_008_0	4	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		1		
H0108	008	0	1	01	01	H0108_008_0	4	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H0108	009	0	1	02	01	H0108_009_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H0108	009	0	1	02	01	H0108_009_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H0108	009	0	1	02	01	H0108_009_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H0108	009	0	1	02	01	H0108_009_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H0108	009	0	1	02	01	H0108_009_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					602.00	33																														33							33					33				33			33	2	3	
H0108	009	0	1	02	01	H0108_009_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					509.00	33																														33							33					33				33			33			
H0108	009	0	1	02	01	H0108_009_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H0108	009	0	1	02	01	H0108_009_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H0108	009	0	1	02	01	H0108_009_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H0108	009	0	1	02	01	H0108_009_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	1
H0108	010	0	1	02	01	H0108_010_0	10	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					723.00	33																														33							33					33				33			33	2	3	
H0108	010	0	1	02	01	H0108_010_0	10	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H0108	010	0	1	02	01	H0108_010_0	10	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H0108	010	0	1	02	01	H0108_010_0	10	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H0108	010	0	1	02	01	H0108_010_0	10	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H0108	010	0	1	02	01	H0108_010_0	10	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					608.00	33																														33							33					33				33			33			
H0108	010	0	1	02	01	H0108_010_0	10	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H0108	010	0	1	02	01	H0108_010_0	10	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H0108	010	0	1	02	01	H0108_010_0	10	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H0108	010	0	1	02	01	H0108_010_0	10	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	1
H0108	011	0	1	01	01	H0108_011_0	10	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H0108	011	0	1	01	01	H0108_011_0	10	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					991.00	33																														33							33					33				33			33	2	3	
H0108	011	0	1	01	01	H0108_011_0	10	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H0108	011	0	1	01	01	H0108_011_0	10	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H0108	011	0	1	01	01	H0108_011_0	10	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		1		
H0108	011	0	1	01	01	H0108_011_0	10	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H0108	011	0	1	01	01	H0108_011_0	10	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					893.00	33																														33							33					33				33			33			
H0108	011	0	1	01	01	H0108_011_0	10	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H0108	011	0	1	01	01	H0108_011_0	10	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H0108	011	0	1	01	01	H0108_011_0	10	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H0108	012	0	1	02	01	H0108_012_0	8	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H0108	012	0	1	02	01	H0108_012_0	8	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	1
H0108	012	0	1	02	01	H0108_012_0	8	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H0108	012	0	1	02	01	H0108_012_0	8	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H0108	012	0	1	02	01	H0108_012_0	8	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H0108	012	0	1	02	01	H0108_012_0	8	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					918.00	33																														33							33					33				33			33	2	3	
H0108	012	0	1	02	01	H0108_012_0	8	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H0108	012	0	1	02	01	H0108_012_0	8	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H0108	012	0	1	02	01	H0108_012_0	8	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H0108	012	0	1	02	01	H0108_012_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					791.00	33																														33							33					33				33			33			
H0108	013	0	1	01	01	H0108_013_0	8	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H0108	013	0	1	01	01	H0108_013_0	8	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H0108	013	0	1	01	01	H0108_013_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					687.00	33																														33							33					33				33			33			
H0108	013	0	1	01	01	H0108_013_0	8	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H0108	013	0	1	01	01	H0108_013_0	8	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H0108	013	0	1	01	01	H0108_013_0	8	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		1		
H0108	013	0	1	01	01	H0108_013_0	8	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H0108	013	0	1	01	01	H0108_013_0	8	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H0108	013	0	1	01	01	H0108_013_0	8	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					786.00	33																														33							33					33				33			33	2	3	
H0108	013	0	1	01	01	H0108_013_0	8	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H0108	014	0	1	02	01	H0108_014_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H0108	014	0	1	02	01	H0108_014_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H0108	014	0	1	02	01	H0108_014_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H0108	014	0	1	02	01	H0108_014_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H0108	014	0	1	02	01	H0108_014_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					790.00	33																														33							33					33				33			33			
H0108	014	0	1	02	01	H0108_014_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	1
H0108	014	0	1	02	01	H0108_014_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H0108	014	0	1	02	01	H0108_014_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H0108	014	0	1	02	01	H0108_014_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H0108	014	0	1	02	01	H0108_014_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					911.00	33																														33							33					33				33			33	2	3	
H0108	021	0	1	01	01	H0108_021_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H0108	021	0	1	01	01	H0108_021_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H0108	021	0	1	01	01	H0108_021_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					868.00	33																														33							33					33				33			33	2	3	
H0108	021	0	1	01	01	H0108_021_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H0108	021	0	1	01	01	H0108_021_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H0108	021	0	1	01	01	H0108_021_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		1		
H0108	021	0	1	01	01	H0108_021_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H0108	021	0	1	01	01	H0108_021_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					753.00	33																														33							33					33				33			33			
H0108	021	0	1	01	01	H0108_021_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H0108	021	0	1	01	01	H0108_021_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H0108	022	0	1	01	01	H0108_022_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H0108	022	0	1	01	01	H0108_022_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H0108	022	0	1	01	01	H0108_022_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					874.00	33																														33							33					33				33			33	2	3	
H0108	022	0	1	01	01	H0108_022_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H0108	022	0	1	01	01	H0108_022_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H0108	022	0	1	01	01	H0108_022_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					753.00	33																														33							33					33				33			33			
H0108	022	0	1	01	01	H0108_022_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H0108	022	0	1	01	01	H0108_022_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H0108	022	0	1	01	01	H0108_022_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H0108	022	0	1	01	01	H0108_022_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H0108	023	0	1	01	01	H0108_023_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H0108	023	0	1	01	01	H0108_023_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					822.00	33																														33							33					33				33			33			
H0108	023	0	1	01	01	H0108_023_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H0108	023	0	1	01	01	H0108_023_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		1		
H0108	023	0	1	01	01	H0108_023_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H0108	023	0	1	01	01	H0108_023_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H0108	023	0	1	01	01	H0108_023_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					948.00	33																														33							33					33				33			33	2	3	
H0108	023	0	1	01	01	H0108_023_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H0108	023	0	1	01	01	H0108_023_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H0108	023	0	1	01	01	H0108_023_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H0108	024	0	1	01	01	H0108_024_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H0108	024	0	1	01	01	H0108_024_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H0108	024	0	1	01	01	H0108_024_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H0108	024	0	1	01	01	H0108_024_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					821.00	33																														33							33					33				33			33			
H0108	024	0	1	01	01	H0108_024_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H0108	024	0	1	01	01	H0108_024_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H0108	024	0	1	01	01	H0108_024_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H0108	024	0	1	01	01	H0108_024_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H0108	024	0	1	01	01	H0108_024_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H0108	024	0	1	01	01	H0108_024_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					954.00	33																														33							33					33				33			33	2	3	
H0108	025	0	1	01	01	H0108_025_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		1		
H0108	025	0	1	01	01	H0108_025_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H0108	025	0	1	01	01	H0108_025_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H0108	025	0	1	01	01	H0108_025_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					948.00	33																														33							33					33				33			33	2	3	
H0108	025	0	1	01	01	H0108_025_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H0108	025	0	1	01	01	H0108_025_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H0108	025	0	1	01	01	H0108_025_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H0108	025	0	1	01	01	H0108_025_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H0108	025	0	1	01	01	H0108_025_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					822.00	33																														33							33					33				33			33			
H0108	025	0	1	01	01	H0108_025_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H0108	026	0	1	01	01	H0108_026_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H0108	026	0	1	01	01	H0108_026_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					954.00	33																														33							33					33				33			33	2	3	
H0108	026	0	1	01	01	H0108_026_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H0108	026	0	1	01	01	H0108_026_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H0108	026	0	1	01	01	H0108_026_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H0108	026	0	1	01	01	H0108_026_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H0108	026	0	1	01	01	H0108_026_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					821.00	33																														33							33					33				33			33			
H0108	026	0	1	01	01	H0108_026_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H0108	026	0	1	01	01	H0108_026_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H0108	026	0	1	01	01	H0108_026_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H0108	027	0	1	01	01	H0108_027_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H0108	027	0	1	01	01	H0108_027_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H0108	027	0	1	01	01	H0108_027_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					939.00	33																														33							33					33				33			33	2	3	
H0108	027	0	1	01	01	H0108_027_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H0108	027	0	1	01	01	H0108_027_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H0108	027	0	1	01	01	H0108_027_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		1		
H0108	027	0	1	01	01	H0108_027_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H0108	027	0	1	01	01	H0108_027_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					815.00	33																														33							33					33				33			33			
H0108	027	0	1	01	01	H0108_027_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H0108	027	0	1	01	01	H0108_027_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H0108	028	0	1	01	01	H0108_028_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H0108	028	0	1	01	01	H0108_028_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H0108	028	0	1	01	01	H0108_028_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H0108	028	0	1	01	01	H0108_028_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H0108	028	0	1	01	01	H0108_028_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					946.00	33																														33							33					33				33			33	2	3	
H0108	028	0	1	01	01	H0108_028_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					814.00	33																														33							33					33				33			33			
H0108	028	0	1	01	01	H0108_028_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H0108	028	0	1	01	01	H0108_028_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H0108	028	0	1	01	01	H0108_028_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H0108	028	0	1	01	01	H0108_028_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H0117	005	0	1	01	01	H0117_005_0	8	1	Generic	1	4	010010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		3.00	6.00	9.00																													3.00	6.00	0.00							9.00				3.00					3.00			3.00				
H0117	005	0	1	01	01	H0117_005_0	8	2	Preferred Brand	1	4	000001	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		39.00	78.00	117.00																													39.00	78.00	78.00							117.00				39.00								39.00				
H0117	005	0	1	01	01	H0117_005_0	8	3	Non-Preferred Brand	1	4	100000	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		69.00	138.00	207.00																													69.00	138.00	138.00							207.00				69.00								69.00				
H0117	005	0	1	01	01	H0117_005_0	8	4	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
H0117	007	0	1	01	01	H0117_007_0	6	1	Preferred Generic	1	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
H0117	007	0	1	01	01	H0117_007_0	6	2	Preferred Brand	1	4	010001	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		45.00	90.00	135.00																													45.00	90.00	90.00							135.00				45.00					45.00			45.00				
H0117	007	0	1	01	01	H0117_007_0	6	3	Non-Preferred Brand	1	4	110000	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		95.00	190.00	285.00																													95.00	190.00	190.00							285.00				95.00					95.00			95.00				
H0117	007	0	1	01	01	H0117_007_0	6	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	31													31			31			31		31		31	14					707.00	25																														25							25					25				25			25			
H0137	001	0	1	48	05	H0137_001_0	5	1	Generic	1	4	010000	3	2	011100000001001000000110	31	60	90							2			90								10	31	14			0.00	0.00	0.00	0.00																								0.00																			0.00			0.00	0.00							
H0137	001	0	1	48	05	H0137_001_0	5	4	Specialty Tier	1	4	010001	1	2	111100000001001000000111	31	60	90							2			90								10	31	14	31	14	0.00	0.00	0.00	0.00																								0.00																			0.00			0.00	0.00		0.00	0.00				
H0137	001	0	1	48	05	H0137_001_0	5	3	Non-Preferred Brand	1	4	100000	1	2	111100000001001000000001	31	60	90							2			90								10			31	14	0.00	0.00	0.00	0.00																								0.00																			0.00						0.00	0.00				
H0137	001	0	1	48	05	H0137_001_0	5	2	Preferred Brand	1	4	000001	3	2	111100000001001000000001	31	60	90							2			90								10			31	14	0.00	0.00	0.00	0.00																								0.00																			0.00						0.00	0.00				
H0141	001	0	1	01	01	H0141_001_0	8	1	Generic	1	4	010001	1	2	110100000010001000000101	30		90							2			90							30		31		31	14		0.00		0.00																								0.00																		0.00					0.00			0.00				
H0141	001	0	1	01	01	H0141_001_0	8	4	Specialty Tier	1	4	010010	1	1	110100000010001000000101	30		90							2			90							30		31		31	14					372.41	25		25																							25																	25				25			25			
H0141	001	0	1	01	01	H0141_001_0	8	3	Non-Preferred Brand	1	4	100100	1	2	110100000010001000000101	30		90							2			90							30		31		31	14		95.00		285.00																								285.00																		95.00					95.00			95.00				
H0141	001	0	1	01	01	H0141_001_0	8	2	Preferred Brand	1	4	000101	1	2	110100000010001000000101	30		90							2			90							30		31		31	14		45.00		135.00																								135.00																		45.00					45.00			45.00				
H0150	001	0	1	01	01	H0150_001_0	7	3	Preferred Brand	1	4	000001	1	2	111100000010001000000001	30	60	90							2			90							30				31	14		45.00	90.00	135.00																								125.00																		45.00								45.00				
H0150	001	0	1	01	01	H0150_001_0	7	2	Non-Preferred Generic	3	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		10.00	20.00	30.00																								21.00																		10.00					10.00			10.00		2	2	
H0150	001	0	1	01	01	H0150_001_0	7	1	Preferred Generic	3	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					3.00	6.00	9.00																								0.00																		3.00					3.00					1		
H0150	001	0	1	01	01	H0150_001_0	7	5	Specialty Tier	1	4	010010	1	1	111100000010001000000101	30	60	90							2			90							30		31		31	14					322.26	33	33	33																							33																	33				33			33			
H0150	001	0	1	01	01	H0150_001_0	7	2	Non-Preferred Generic	1	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		10.00	20.00	30.00																								21.00																		10.00					10.00			10.00				
H0150	001	0	1	01	01	H0150_001_0	7	1	Preferred Generic	1	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					3.00	6.00	9.00																								0.00																		3.00					3.00							
H0150	001	0	1	01	01	H0150_001_0	7	4	Non-Preferred Brand	1	4	100100	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		85.00	170.00	255.00																								245.00																		85.00					85.00			85.00				
H0150	023	0	1	02	01	H0150_023_0	6	2	Non-Preferred Generic	1	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		6.00	12.00	18.00																								9.00																		6.00					6.00			6.00				
H0150	023	0	1	02	01	H0150_023_0	6	2	Non-Preferred Generic	3	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		6.00	12.00	18.00																								9.00																		6.00					6.00			6.00		2	2	
H0150	023	0	1	02	01	H0150_023_0	6	1	Preferred Generic	1	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					3.00	6.00	9.00																								0.00																		3.00					3.00							
H0150	023	0	1	02	01	H0150_023_0	6	5	Specialty Tier	1	4	010010	1	1	111100000010001000000101	30	60	90							2			90							30		31		31	14					367.00	33	33	33																							33																	33				33			33			
H0150	023	0	1	02	01	H0150_023_0	6	4	Non-Preferred Brand	1	4	100100	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		85.00	170.00	255.00																								245.00																		85.00					85.00			85.00				
H0150	023	0	1	02	01	H0150_023_0	6	3	Preferred Brand	1	4	000001	1	2	111100000010001000000001	30	60	90							2			90							30				31	14		45.00	90.00	135.00																								125.00																		45.00								45.00				
H0150	023	0	1	02	01	H0150_023_0	6	1	Preferred Generic	3	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					3.00	6.00	9.00																								0.00																		3.00					3.00					1		
H0151	001	0	1	01	01	H0151_001_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H0151	001	0	1	01	01	H0151_001_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H0151	001	0	1	01	01	H0151_001_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H0151	001	0	1	01	01	H0151_001_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H0151	001	0	1	01	01	H0151_001_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					537.00	33		33																														33							33			33				33			33			
H0151	025	0	1	01	01	H0151_025_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															0.00							18.00				6.00					6.00							
H0151	025	0	1	01	01	H0151_025_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00							
H0151	025	0	1	01	01	H0151_025_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H0151	025	0	1	01	01	H0151_025_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H0151	025	0	1	01	01	H0151_025_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					494.00	33		33																														33							33			33				33			33			
H0154	001	0	1	01	01	H0154_001_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001110	31		90							1						90			90	31		31	14				4.00		12.00																															10.00							12.00				4.00					4.00							
H0154	001	0	1	01	01	H0154_001_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000000000111	31																			31		31	14	31	14					455.00	29																																										29				29			29			
H0154	001	0	1	01	01	H0154_001_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001110	31		90							1						90			90	31		31	14				15.00		45.00																															37.50							45.00				15.00					15.00							
H0154	001	0	1	01	01	H0154_001_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010000001001001	31		90							1						90			90	31				31	14		45.00		135.00																															112.50							135.00				45.00								45.00				
H0154	001	0	1	01	01	H0154_001_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000001001001	31		90							1						90			90	31				31	14		75.00		225.00																															187.50							225.00				75.00								75.00				
H0154	011	0	1	01	01	H0154_011_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000001001001	31		90							1						90			90	31				31	14		75.00		225.00																															187.50							225.00				75.00								75.00				
H0154	011	0	1	01	01	H0154_011_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000000000111	31																			31		31	14	31	14					551.00	33																																										33				33			33			
H0154	011	0	1	01	01	H0154_011_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001110	31		90							1						90			90	31		31	14				15.00		45.00																															37.50							45.00				15.00					15.00							
H0154	011	0	1	01	01	H0154_011_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010000001001110	31		90							1						90			90	31		31	14				4.00		12.00																															10.00							12.00				4.00					4.00							
H0154	011	0	1	01	01	H0154_011_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010000001001001	31		90							1						90			90	31				31	14		45.00		135.00																															112.50							135.00				45.00								45.00				
H0248	001	0	1	04	01	H0248_001_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H0248	001	0	1	04	01	H0248_001_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H0248	001	0	1	04	01	H0248_001_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H0248	001	0	1	04	01	H0248_001_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H0248	001	0	1	04	01	H0248_001_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H0248	001	0	1	04	01	H0248_001_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H0248	001	0	1	04	01	H0248_001_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					762.00	33																														33							33					33				33			33	2	3	
H0248	001	0	1	04	01	H0248_001_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H0248	001	0	1	04	01	H0248_001_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					698.00	33																														33							33					33				33			33			
H0248	001	0	1	04	01	H0248_001_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	1
H0294	002	0	1	04	01	H0294_002_0	6	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					8.00	16.00	24.00																						8.00	16.00	20.00																		8.00					8.00							
H0294	002	0	1	04	01	H0294_002_0	6	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
H0294	002	0	1	04	01	H0294_002_0	6	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
H0294	002	0	1	04	01	H0294_002_0	6	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					885.00	33	33	33																					33	33	33																	33				33			33			
H0294	004	0	1	04	01	H0294_004_0	6	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
H0294	004	0	1	04	01	H0294_004_0	6	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					828.00	33	33	33																					33	33	33																	33				33			33			
H0294	004	0	1	04	01	H0294_004_0	6	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
H0294	004	0	1	04	01	H0294_004_0	6	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					8.00	16.00	24.00																						8.00	16.00	20.00																		8.00					8.00							
H0294	008	0	1	04	01	H0294_008_0	6	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					8.00	16.00	24.00																						8.00	16.00	20.00																		8.00					8.00							
H0294	008	0	1	04	01	H0294_008_0	6	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
H0294	008	0	1	04	01	H0294_008_0	6	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
H0294	008	0	1	04	01	H0294_008_0	6	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					865.00	33	33	33																					33	33	33																	33				33			33			
H0302	001	0	1	01	01	H0302_001_0	6	4	Specialty Tier	1	4	110001	1	1	100010010010000000000101				30			30													30		31		31	14													346.00	33							346.00	33																										33				33			33			
H0302	001	0	1	01	01	H0302_001_0	6	3	Non-Preferred Brand	1	4	100000	1	2	100011111110001000000001				30	60	90	30	60	90	1			90							30				31	14										80.00	160.00	240.00						85.00	170.00	255.00								240.00																		85.00								85.00				
H0302	001	0	1	01	01	H0302_001_0	6	2	Preferred Brand	1	4	000001	1	2	100011111110001000000001				30	60	90	30	60	90	1			90							30				31	14										40.00	80.00	120.00						45.00	90.00	135.00								120.00																		45.00								45.00				
H0302	001	0	1	01	01	H0302_001_0	6	1	Generic	1	4	010000	1	2	000011111110001000000100				30	60	90	30	60	90	1			90							30		31													4.00	8.00	12.00						6.00	12.00	18.00								12.00																		6.00					6.00							
H0302	006	0	1	01	01	H0302_006_0	6	1	Generic	1	4	010000	1	1	000011111110001000000100				30	60	90	30	60	90	1			90							30		31																5.00	22	22	22					5.00	25	25	25							25																	25				25						
H0302	006	0	1	01	01	H0302_006_0	6	2	Preferred Brand	1	4	000001	1	1	100011111110001000000001				30	60	90	30	60	90	1			90							30				31	14													29.00	22	22	22					29.00	25	25	25							25																	25							25			
H0302	006	0	1	01	01	H0302_006_0	6	3	Non-Preferred Brand	1	4	100000	1	1	100011111110001000000001				30	60	90	30	60	90	1			90							30				31	14													35.00	22	22	22					35.00	25	25	25							25																	25							25			
H0302	006	0	1	01	01	H0302_006_0	6	4	Specialty Tier	1	4	110001	1	1	100010010010000000000101				30			30													30		31		31	14													214.00	25							214.00	25																										25				25			25			
H0302	007	0	1	01	01	H0302_007_0	5	4	Specialty Tier	1	4	110001	1	1	100010010010000000000101				30			30													30		31		31	14													239.00	33							239.00	33																										33				33			33			
H0302	007	0	1	01	01	H0302_007_0	5	3	Non-Preferred Brand	1	4	100000	1	2	100011111110001000000001				30	60	90	30	60	90	1			90							30				31	14										80.00	160.00	240.00						85.00	170.00	255.00								240.00																		85.00								85.00				
H0302	007	0	1	01	01	H0302_007_0	5	1	Generic	1	4	010000	1	2	000011111110001000000100				30	60	90	30	60	90	1			90							30		31													4.00	8.00	12.00						6.00	12.00	18.00								12.00																		6.00					6.00							
H0302	007	0	1	01	01	H0302_007_0	5	2	Preferred Brand	1	4	000001	1	2	100011111110001000000001				30	60	90	30	60	90	1			90							30				31	14										30.00	60.00	90.00						35.00	70.00	105.00								90.00																		35.00								35.00				
H0303	013	0	1	01	01	H0303_013_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H0303	013	0	1	01	01	H0303_013_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00							
H0303	013	0	1	01	01	H0303_013_0	8	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H0303	013	0	1	01	01	H0303_013_0	8	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H0303	013	0	1	01	01	H0303_013_0	8	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					563.00	33		33																														33							33			33				33			33			
H0303	015	0	1	01	01	H0303_015_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					7.00		21.00																															14.00							21.00				7.00					7.00							
H0303	015	0	1	01	01	H0303_015_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H0303	015	0	1	01	01	H0303_015_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H0303	015	0	1	01	01	H0303_015_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					538.00	33		33																														33							33			33				33			33			
H0303	015	0	1	01	01	H0303_015_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					4.00		12.00																															8.00							12.00				4.00					4.00							
H0307	008	0	1	02	01	H0307_008_0	9	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H0307	008	0	1	02	01	H0307_008_0	9	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					749.00	33																														33							33					33				33			33	2	3	
H0307	008	0	1	02	01	H0307_008_0	9	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H0307	008	0	1	02	01	H0307_008_0	9	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H0307	008	0	1	02	01	H0307_008_0	9	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	1
H0307	008	0	1	02	01	H0307_008_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					681.00	33																														33							33					33				33			33			
H0307	008	0	1	02	01	H0307_008_0	9	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H0307	008	0	1	02	01	H0307_008_0	9	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H0307	008	0	1	02	01	H0307_008_0	9	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H0307	008	0	1	02	01	H0307_008_0	9	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H0307	009	0	1	01	01	H0307_009_0	12	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					815.00	33																														33							33					33				33			33	2	3	
H0307	009	0	1	01	01	H0307_009_0	12	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H0307	009	0	1	01	01	H0307_009_0	12	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H0307	009	0	1	01	01	H0307_009_0	12	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H0307	009	0	1	01	01	H0307_009_0	12	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H0307	009	0	1	01	01	H0307_009_0	12	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H0307	009	0	1	01	01	H0307_009_0	12	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					758.00	33																														33							33					33				33			33			
H0307	009	0	1	01	01	H0307_009_0	12	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	1
H0307	009	0	1	01	01	H0307_009_0	12	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H0307	009	0	1	01	01	H0307_009_0	12	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H0307	011	0	1	01	01	H0307_011_0	8	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H0307	011	0	1	01	01	H0307_011_0	8	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	1
H0307	011	0	1	01	01	H0307_011_0	8	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H0307	011	0	1	01	01	H0307_011_0	8	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H0307	011	0	1	01	01	H0307_011_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					448.00	33																														33							33					33				33			33			
H0307	011	0	1	01	01	H0307_011_0	8	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					512.00	33																														33							33					33				33			33	2	3	
H0307	011	0	1	01	01	H0307_011_0	8	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H0307	011	0	1	01	01	H0307_011_0	8	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H0307	011	0	1	01	01	H0307_011_0	8	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H0307	011	0	1	01	01	H0307_011_0	8	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H0307	012	0	1	02	01	H0307_012_0	8	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H0307	012	0	1	02	01	H0307_012_0	8	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H0307	012	0	1	02	01	H0307_012_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					725.00	33																														33							33					33				33			33			
H0307	012	0	1	02	01	H0307_012_0	8	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	1
H0307	012	0	1	02	01	H0307_012_0	8	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H0307	012	0	1	02	01	H0307_012_0	8	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H0307	012	0	1	02	01	H0307_012_0	8	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H0307	012	0	1	02	01	H0307_012_0	8	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					853.00	33																														33							33					33				33			33	2	3	
H0307	012	0	1	02	01	H0307_012_0	8	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H0307	012	0	1	02	01	H0307_012_0	8	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H0307	013	0	1	02	01	H0307_013_0	8	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H0307	013	0	1	02	01	H0307_013_0	8	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H0307	013	0	1	02	01	H0307_013_0	8	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					839.00	33																														33							33					33				33			33	2	3	
H0307	013	0	1	02	01	H0307_013_0	8	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H0307	013	0	1	02	01	H0307_013_0	8	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H0307	013	0	1	02	01	H0307_013_0	8	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H0307	013	0	1	02	01	H0307_013_0	8	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	1
H0307	013	0	1	02	01	H0307_013_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					713.00	33																														33							33					33				33			33			
H0307	013	0	1	02	01	H0307_013_0	8	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H0307	013	0	1	02	01	H0307_013_0	8	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H0307	015	0	1	02	01	H0307_015_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H0307	015	0	1	02	01	H0307_015_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H0307	015	0	1	02	01	H0307_015_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H0307	015	0	1	02	01	H0307_015_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H0307	015	0	1	02	01	H0307_015_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					876.00	33																														33							33					33				33			33	2	3	
H0307	015	0	1	02	01	H0307_015_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					743.00	33																														33							33					33				33			33			
H0307	015	0	1	02	01	H0307_015_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H0307	015	0	1	02	01	H0307_015_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H0307	015	0	1	02	01	H0307_015_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H0307	015	0	1	02	01	H0307_015_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	1
H0316	002	0	1	02	01	H0316_002_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H0316	002	0	1	02	01	H0316_002_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H0316	002	0	1	02	01	H0316_002_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H0316	002	0	1	02	01	H0316_002_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H0316	002	0	1	02	01	H0316_002_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					502.00	33		33																														33							33			33				33			33			
H0316	014	0	1	01	01	H0316_014_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H0316	014	0	1	01	01	H0316_014_0	8	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H0316	014	0	1	01	01	H0316_014_0	8	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H0316	014	0	1	01	01	H0316_014_0	8	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					403.00	33		33																														33							33			33				33			33			
H0316	014	0	1	01	01	H0316_014_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H0317	001	0	1	04	01	H0317_001_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					999.00	33																														33							33					33				33			33	2	3	
H0317	001	0	1	04	01	H0317_001_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H0317	001	0	1	04	01	H0317_001_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H0317	001	0	1	04	01	H0317_001_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H0317	001	0	1	04	01	H0317_001_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	1
H0317	001	0	1	04	01	H0317_001_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					957.00	33																														33							33					33				33			33			
H0317	001	0	1	04	01	H0317_001_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H0317	001	0	1	04	01	H0317_001_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H0317	001	0	1	04	01	H0317_001_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H0317	001	0	1	04	01	H0317_001_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H0317	004	0	1	04	01	H0317_004_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H0317	004	0	1	04	01	H0317_004_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H0317	004	0	1	04	01	H0317_004_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					885.00	33																														33							33					33				33			33	2	3	
H0317	004	0	1	04	01	H0317_004_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H0317	004	0	1	04	01	H0317_004_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H0317	004	0	1	04	01	H0317_004_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H0317	004	0	1	04	01	H0317_004_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	1
H0317	004	0	1	04	01	H0317_004_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					871.00	33																														33							33					33				33			33			
H0317	004	0	1	04	01	H0317_004_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H0317	004	0	1	04	01	H0317_004_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H0317	006	0	1	04	01	H0317_006_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H0317	006	0	1	04	01	H0317_006_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H0317	006	0	1	04	01	H0317_006_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H0317	006	0	1	04	01	H0317_006_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H0317	006	0	1	04	01	H0317_006_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					883.00	33																														33							33					33				33			33	2	3	
H0317	006	0	1	04	01	H0317_006_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					829.00	33																														33							33					33				33			33			
H0317	006	0	1	04	01	H0317_006_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	1
H0317	006	0	1	04	01	H0317_006_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H0317	006	0	1	04	01	H0317_006_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H0317	006	0	1	04	01	H0317_006_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H0317	007	0	1	04	01	H0317_007_0	4	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	1
H0317	007	0	1	04	01	H0317_007_0	4	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H0317	007	0	1	04	01	H0317_007_0	4	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H0317	007	0	1	04	01	H0317_007_0	4	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H0317	007	0	1	04	01	H0317_007_0	4	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					973.00	33																														33							33					33				33			33	2	3	
H0317	007	0	1	04	01	H0317_007_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H0317	007	0	1	04	01	H0317_007_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H0317	007	0	1	04	01	H0317_007_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H0317	007	0	1	04	01	H0317_007_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H0317	007	0	1	04	01	H0317_007_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					954.00	33																														33							33					33				33			33			
H0318	002	0	1	01	01	H0318_002_0	7	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					7.00	14.00	21.00																													7.00	14.00	14.00					7.00	14.00	21.00					7.00				7.00							
H0318	002	0	1	01	01	H0318_002_0	7	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H0318	002	0	1	01	01	H0318_002_0	7	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					344.16	33	33	33																												33	33	33					33	33	33				33			33			33			
H0318	002	0	1	01	01	H0318_002_0	7	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H0318	002	0	1	01	01	H0318_002_0	7	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H0320	005	0	1	01	01	H0320_005_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		2.00		6.00																						2.00		4.00																		2.00					2.00			2.00				
H0320	005	0	1	01	01	H0320_005_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		11.00		33.00																						11.00		22.00																		11.00					11.00			11.00				
H0320	005	0	1	01	01	H0320_005_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		45.00		135.00																						45.00		122.50																		45.00					45.00			45.00				
H0320	005	0	1	01	01	H0320_005_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		95.00		285.00																						95.00		237.50																		95.00					95.00			95.00				
H0320	005	0	1	01	01	H0320_005_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					797.00	33																							33																			33				33			33			
H0320	006	0	1	01	01	H0320_006_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		2.00		6.00																						2.00		4.00																		2.00					2.00			2.00				
H0320	006	0	1	01	01	H0320_006_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		11.00		33.00																						11.00		22.00																		11.00					11.00			11.00				
H0320	006	0	1	01	01	H0320_006_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		45.00		135.00																						45.00		112.50																		45.00					45.00			45.00				
H0320	006	0	1	01	01	H0320_006_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		95.00		285.00																						95.00		237.50																		95.00					95.00			95.00				
H0320	006	0	1	01	01	H0320_006_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					458.00	33																							33																			33				33			33			
H0332	002	0	1	01	01	H0332_002_0	5	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													5.00		12.50						10.00		30.00																										10.00					10.00							
H0332	002	0	1	01	01	H0332_002_0	5	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000000000100				30		90	30		90	1										30		31													30.00		75.00						33.00		99.00																										33.00					33.00							
H0332	002	0	1	01	01	H0332_002_0	5	3	Preferred Brand	1	4	000001	1	2	100010110110000000000001				30		90	30		90	1										30				31	1										40.00		100.00						45.00		135.00																										45.00								45.00				
H0332	002	0	1	01	01	H0332_002_0	5	4	Non-Preferred Brand	1	4	100000	1	2	100010110110000000000001				30		90	30		90	1										30				31	1										80.00		200.00						90.00		270.00																										90.00								90.00				
H0332	002	0	1	01	01	H0332_002_0	5	5	Specialty Tier	1	4	100000	1	1	100010110110000000000001				30		90	30		90	1										30				31	1													31.00	31		31					31.00	31		31																								31							31			
H0332	002	0	1	01	01	H0332_002_0	5	1	Preferred Generic	3	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													5.00		12.50						10.00		30.00																										10.00					10.00					1		
H0332	004	0	1	02	01	H0332_004_0	5	5	Specialty Tier	1	4	100000	1	1	100010110110000000000001				30		90	30		90	1										30				31	1													31.00	31		31					31.00	31		31																								31							31			
H0332	004	0	1	02	01	H0332_004_0	5	1	Preferred Generic	3	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													5.00		12.50						10.00		30.00																										10.00					10.00					1		
H0332	004	0	1	02	01	H0332_004_0	5	4	Non-Preferred Brand	1	4	100000	1	2	100010110110000000000001				30		90	30		90	1										30				31	1										80.00		200.00						90.00		270.00																										90.00								90.00				
H0332	004	0	1	02	01	H0332_004_0	5	3	Preferred Brand	1	4	000001	1	2	100010110110000000000001				30		90	30		90	1										30				31	1										40.00		100.00						45.00		135.00																										45.00								45.00				
H0332	004	0	1	02	01	H0332_004_0	5	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000000000100				30		90	30		90	1										30		31													30.00		75.00						33.00		99.00																										33.00					33.00							
H0332	004	0	1	02	01	H0332_004_0	5	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													5.00		12.50						10.00		30.00																										10.00					10.00							
H0332	006	0	1	01	01	H0332_006_0	4	1	Preferred Generic	3	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		30.00																										10.00					10.00					1		
H0332	006	0	1	01	01	H0332_006_0	4	5	Specialty Tier	1	4	100000	1	1	100010110110000000000001				30		90	30		90	1										30				31	1													30.00	30		30					30.00	30		30																								30							30			
H0332	006	0	1	01	01	H0332_006_0	4	4	Non-Preferred Brand	1	4	100000	1	2	100010110110000000000001				30		90	30		90	1										30				31	1										50.00		150.00						60.00		180.00																										60.00								60.00				
H0332	006	0	1	01	01	H0332_006_0	4	3	Preferred Brand	1	4	000001	1	2	100010110110000000000001				30		90	30		90	1										30				31	1										20.00		60.00						30.00		90.00																										30.00								30.00				
H0332	006	0	1	01	01	H0332_006_0	4	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000000000100				30		90	30		90	1										30		31													20.00		60.00						30.00		90.00																										30.00					30.00							
H0332	006	0	1	01	01	H0332_006_0	4	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		30.00																										10.00					10.00							
H0351	014	0	1	01	01	H0351_014_0	4	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		95.00	190.00	285.00																													95.00	190.00	275.00					95.00	190.00	285.00				95.00								95.00				
H0351	014	0	1	01	01	H0351_014_0	4	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		45.00	90.00	135.00																													45.00	90.00	125.00					45.00	90.00	135.00				45.00								45.00				
H0351	014	0	1	01	01	H0351_014_0	4	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				15.00	30.00	45.00																													15.00	30.00	30.00					15.00	30.00	45.00				15.00					15.00							
H0351	014	0	1	01	01	H0351_014_0	4	1	Preferred Generic	1	4	001000	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				3.00	6.00	9.00																													3.00	6.00	6.00					3.00	6.00	9.00				3.00					3.00							
H0351	014	0	1	01	01	H0351_014_0	4	5	Specialty Tier	1	4	010010	1	1	111100000010000111111111	30	60	90							1				30	60	90	30	60	90	30		34	14	34	14					545.00	33	33	33																												33	33	33					33	33	33			33				33			33			
H0351	029	0	1	01	01	H0351_029_0	5	1	Preferred Generic	1	2	001000		2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				0.00	0.00	0.00																													0.00	0.00	0.00					0.00	0.00	0.00				0.00					0.00							
H0351	029	0	1	01	01	H0351_029_0	5	2	Non-Preferred Generic	1	2	000100		2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				11.00	22.00	33.00																													11.00	22.00	22.00					11.00	22.00	33.00				11.00					11.00							
H0351	029	0	1	01	01	H0351_029_0	5	3	Preferred Brand	1	2	000001		2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		41.00	82.00	123.00																													41.00	82.00	113.00					41.00	82.00	123.00				41.00								41.00				
H0351	029	0	1	01	01	H0351_029_0	5	4	Non-Preferred Brand	1	2	100000		2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		95.00	190.00	285.00																													95.00	190.00	275.00					95.00	190.00	285.00				95.00								95.00				
H0351	029	0	1	01	01	H0351_029_0	5	5	Specialty Tier	1	2	010010		1	111100000010000111111111	30	60	90							1				30	60	90	30	60	90	30		34	14	34	14					456.00	25	25	25																												25	25	25					25	25	25			25				25			25			
H0351	035	0	1	01	01	H0351_035_0	5	1	Preferred Generic	1	4	001000	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				3.00	6.00	9.00																													3.00	6.00	6.00					3.00	6.00	9.00				3.00					3.00							
H0351	035	0	1	01	01	H0351_035_0	5	5	Specialty Tier	1	4	010010	1	1	111100000010000111111111	30	60	90							1				30	60	90	30	60	90	30		34	14	34	14					551.00	33	33	33																												33	33	33					33	33	33			33				33			33			
H0351	035	0	1	01	01	H0351_035_0	5	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		95.00	190.00	285.00																													95.00	190.00	275.00					95.00	190.00	285.00				95.00								95.00				
H0351	035	0	1	01	01	H0351_035_0	5	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				15.00	30.00	45.00																													15.00	30.00	30.00					15.00	30.00	45.00				15.00					15.00							
H0351	035	0	1	01	01	H0351_035_0	5	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		45.00	90.00	135.00																													45.00	90.00	125.00					45.00	90.00	135.00				45.00								45.00				
H0351	036	0	1	01	01	H0351_036_0	5	1	Preferred Generic	1	4	001000	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				3.00	6.00	9.00																													3.00	6.00	6.00					3.00	6.00	9.00				3.00					3.00							
H0351	036	0	1	01	01	H0351_036_0	5	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				15.00	30.00	45.00																													15.00	30.00	30.00					15.00	30.00	45.00				15.00					15.00							
H0351	036	0	1	01	01	H0351_036_0	5	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		45.00	90.00	135.00																													45.00	90.00	125.00					45.00	90.00	135.00				45.00								45.00				
H0351	036	0	1	01	01	H0351_036_0	5	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		95.00	190.00	285.00																													95.00	190.00	275.00					95.00	190.00	285.00				95.00								95.00				
H0351	036	0	1	01	01	H0351_036_0	5	5	Specialty Tier	1	4	010010	1	1	111100000010000111111111	30	60	90							1				30	60	90	30	60	90	30		34	14	34	14					405.00	33	33	33																												33	33	33					33	33	33			33				33			33			
H0351	038	0	1	01	01	H0351_038_0	5	5	Specialty Tier	1	4	010010	1	1	111100000010000111111111	30	60	90							1				30	60	90	30	60	90	30		34	14	34	14					460.00	33	33	33																												33	33	33					33	33	33			33				33			33			
H0351	038	0	1	01	01	H0351_038_0	5	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		95.00	190.00	285.00																													95.00	190.00	275.00					95.00	190.00	285.00				95.00								95.00				
H0351	038	0	1	01	01	H0351_038_0	5	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		44.00	88.00	132.00																													44.00	88.00	122.00					44.00	88.00	132.00				44.00								44.00				
H0351	038	0	1	01	01	H0351_038_0	5	1	Preferred Generic	1	4	001000	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				0.00	0.00	0.00																													0.00	0.00	0.00					0.00	0.00	0.00				0.00					0.00							
H0351	038	0	1	01	01	H0351_038_0	5	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				15.00	30.00	45.00																													15.00	30.00	30.00					15.00	30.00	45.00				15.00					15.00							
H0351	040	0	1	01	01	H0351_040_0	5	5	Specialty Tier	1	4	010010	1	1	111100000010000111111111	30	60	90							1				30	60	90	30	60	90	30		34	14	34	14					521.00	33	33	33																												33	33	33					33	33	33			33				33			33			
H0351	040	0	1	01	01	H0351_040_0	5	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		95.00	190.00	285.00																													95.00	190.00	275.00					95.00	190.00	285.00				95.00								95.00				
H0351	040	0	1	01	01	H0351_040_0	5	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		44.00	88.00	132.00																													44.00	88.00	122.00					44.00	88.00	132.00				44.00								44.00				
H0351	040	0	1	01	01	H0351_040_0	5	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				15.00	30.00	45.00																													15.00	30.00	30.00					15.00	30.00	45.00				15.00					15.00							
H0351	040	0	1	01	01	H0351_040_0	5	1	Preferred Generic	1	4	001000	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				0.00	0.00	0.00																													0.00	0.00	0.00					0.00	0.00	0.00				0.00					0.00							
H0351	041	0	1	01	01	H0351_041_0	4	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		95.00	190.00	285.00																													95.00	190.00	275.00					95.00	190.00	285.00				95.00								95.00				
H0351	041	0	1	01	01	H0351_041_0	4	5	Specialty Tier	1	4	010010	1	1	111100000010000111111111	30	60	90							1				30	60	90	30	60	90	30		34	14	34	14					581.00	33	33	33																												33	33	33					33	33	33			33				33			33			
H0351	041	0	1	01	01	H0351_041_0	4	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		44.00	88.00	132.00																													44.00	88.00	122.00					44.00	88.00	132.00				44.00								44.00				
H0351	041	0	1	01	01	H0351_041_0	4	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				15.00	30.00	45.00																													15.00	30.00	30.00					15.00	30.00	45.00				15.00					15.00							
H0351	041	0	1	01	01	H0351_041_0	4	1	Preferred Generic	1	4	001000	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				0.00	0.00	0.00																													0.00	0.00	0.00					0.00	0.00	0.00				0.00					0.00							
H0354	001	0	1	01	01	H0354_001_0	9	4	Non-Preferred Brand	1	4	100100	1	2	111100000010101000000111	30	60	90							1	30		90							30		31	1	31	1		75.00	150.00	225.00																						75.00		150.00																		75.00				2.41	75.00		2.41	75.00				
H0354	001	0	1	01	01	H0354_001_0	9	5	Specialty Tier	1	4	010010	1	1	111100000010101000000111	30	60	90							1	30		90							30		31	1	31	1					478.36	33	33	33																					33		33																	33				33			33			
H0354	001	0	1	01	01	H0354_001_0	9	1	Preferred Generic	3	4	001001	1	2	111100000010101000000111	30	60	90							1	30		90							30		31	1	31	1		3.00	6.00	9.00																						3.00		6.00																		3.00				.09	3.00		.09	3.00		1		
H0354	001	0	1	01	01	H0354_001_0	9	2	Non-Preferred Generic	3	4	000101	1	2	111100000010101000000111	30	60	90							1	30		90							30		31	1	31	1		5.00	10.00	15.00																						5.00		10.00																		5.00				.16	5.00		.16	5.00		1		
H0354	001	0	1	01	01	H0354_001_0	9	3	Preferred Brand	1	4	000101	1	2	111100000010101000000111	30	60	90							1	30		90							30		31	1	31	1		45.00	90.00	135.00																						45.00		90.00																		45.00				1.45	45.00		1.45	45.00				
H0354	001	0	1	01	01	H0354_001_0	9	1	Preferred Generic	1	4	001001	1	2	111100000010101000000111	30	60	90							1	30		90							30		31	1	31	1		3.00	6.00	9.00																						3.00		6.00																		3.00				.09	3.00		.09	3.00				
H0354	001	0	1	01	01	H0354_001_0	9	2	Non-Preferred Generic	1	4	000101	1	2	111100000010101000000111	30	60	90							1	30		90							30		31	1	31	1		5.00	10.00	15.00																						5.00		10.00																		5.00				.16	5.00		.16	5.00				
H0354	018	0	1	01	01	H0354_018_0	9	3	Preferred Brand	1	4	000101	1	2	111100000010101000000111	30	60	90							1	30		90							30		31	1	31	1		35.00	70.00	105.00																						35.00		70.00																		35.00				1.12	35.00		1.12	35.00				
H0354	018	0	1	01	01	H0354_018_0	9	4	Non-Preferred Brand	1	4	100100	1	2	111100000010101000000111	30	60	90							1	30		90							30		31	1	31	1		70.00	140.00	210.00																						70.00		140.00																		70.00				2.25	70.00		2.25	70.00				
H0354	018	0	1	01	01	H0354_018_0	9	1	Preferred Generic	1	4	001001	1	2	111100000010101000000111	30	60	90							1	30		90							30		31	1	31	1		0.00	0.00	0.00																						0.00		0.00																		0.00				0.00	0.00		0.00	0.00				
H0354	018	0	1	01	01	H0354_018_0	9	2	Non-Preferred Generic	1	4	000101	1	2	111100000010101000000111	30	60	90							1	30		90							30		31	1	31	1		5.00	10.00	15.00																						5.00		10.00																		5.00				.16	5.00		.16	5.00				
H0354	018	0	1	01	01	H0354_018_0	9	5	Specialty Tier	1	4	010010	1	1	111100000010101000000111	30	60	90							1	30		90							30		31	1	31	1					466.57	33	33	33																					33		33																	33				33			33			
H0354	018	0	1	01	01	H0354_018_0	9	1	Preferred Generic	3	4	001001	1	2	111100000010101000000111	30	60	90							1	30		90							30		31	1	31	1		0.00	0.00	0.00																						0.00		0.00																		0.00				0.00	0.00		0.00	0.00		1		
H0354	018	0	1	01	01	H0354_018_0	9	2	Non-Preferred Generic	3	4	000101	1	2	111100000010101000000111	30	60	90							1	30		90							30		31	1	31	1		5.00	10.00	15.00																						5.00		10.00																		5.00				0.16	5.00		0.16	5.00		1		
H0354	021	0	1	01	01	H0354_021_0	9	5	Specialty Tier	1	4	010010	1	1	111100000010101000000111	30	60	90							1	30		90							30		31	1	31	1					482.47	33	33	33																					33		33																	33				33			33			
H0354	021	0	1	01	01	H0354_021_0	9	1	Preferred Generic	3	4	001001	1	2	111100000010101000000111	30	60	90							1	30		90							30		31	1	31	1		2.00	4.00	6.00																						2.00		4.00																		2.00				0.06	2.00		0.06	2.00		1		
H0354	021	0	1	01	01	H0354_021_0	9	2	Non-Preferred Generic	3	4	000101	1	2	111100000010101000000111	30	60	90							1	30		90							30		31	1	31	1		5.00	10.00	15.00																						5.00		10.00																		5.00				0.16	5.00		0.16	5.00		1		
H0354	021	0	1	01	01	H0354_021_0	9	3	Preferred Brand	1	4	000101	1	2	111100000010101000000111	30	60	90							1	30		90							30		31	1	31	1		45.00	90.00	135.00																						45.00		90.00																		45.00				1.45	45.00		1.45	45.00				
H0354	021	0	1	01	01	H0354_021_0	9	4	Non-Preferred Brand	1	4	100100	1	2	111100000010101000000111	30	60	90							1	30		90							30		31	1	31	1		75.00	150.00	225.00																						75.00		150.00																		75.00				2.41	75.00		2.41	75.00				
H0354	021	0	1	01	01	H0354_021_0	9	2	Non-Preferred Generic	1	4	000101	1	2	111100000010101000000111	30	60	90							1	30		90							30		31	1	31	1		5.00	10.00	15.00																						5.00		10.00																		5.00				0.16	5.00		0.16	5.00				
H0354	021	0	1	01	01	H0354_021_0	9	1	Preferred Generic	1	4	001001	1	2	111100000010101000000111	30	60	90							1	30		90							30		31	1	31	1		2.00	4.00	6.00																						2.00		4.00																		2.00				0.06	2.00		0.06	2.00				
H0401	002	0	1	01	01	H0401_002_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															0.00							9.00				3.00					3.00							
H0401	002	0	1	01	01	H0401_002_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															0.00							18.00				6.00					6.00							
H0401	002	0	1	01	01	H0401_002_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H0401	002	0	1	01	01	H0401_002_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H0401	002	0	1	01	01	H0401_002_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					553.00	33		33																														33							33			33				33			33			
H0435	002	0	1	01	01	H0435_002_0	10	3	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		40.00	80.00	100.00																						40.00	80.00	100.00																		40.00								40.00				
H0435	002	0	1	01	01	H0435_002_0	10	4	Specialty Tier	1	4	100000	1	1	110000000010100000000001	30										30									30				31	14					787.60	33																							33																			33							33			
H0435	002	0	1	01	01	H0435_002_0	10	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		31	14				10.00	20.00	25.00																						10.00	20.00	25.00																		10.00					10.00							
H0435	002	0	1	01	01	H0435_002_0	10	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		31	14				4.00	8.00	10.00																						4.00	8.00	10.00																		4.00					4.00							
H0435	003	0	1	01	01	H0435_003_0	11	4	Specialty Tier	1	4	100000	1	1	110000000010100000000001	30										30									30				31	14					787.60	33																							33																			33							33			
H0435	003	0	1	01	01	H0435_003_0	11	3	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		40.00	80.00	100.00																						40.00	80.00	100.00																		40.00								40.00				
H0435	003	0	1	01	01	H0435_003_0	11	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		31	14				10.00	20.00	25.00																						10.00	20.00	25.00																		10.00					10.00							
H0435	003	0	1	01	01	H0435_003_0	11	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		31	14				4.00	8.00	10.00																						4.00	8.00	10.00																		4.00					4.00							
H0490	004	0	1	01	01	H0490_004_0	7	1	Generic	1	4	010000	1	2	011100000010111000000110	31	60	90							1	31	60	90							31		31	14				0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00							
H0490	004	0	1	01	01	H0490_004_0	7	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	31	60	90							1	31	60	90							31				31	14		45.00	90.00	135.00																						45.00	90.00	135.00																		45.00								45.00				
H0490	004	0	1	01	01	H0490_004_0	7	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	31	60	90							1	31	60	90							31				31	14		95.00	190.00	285.00																						95.00	190.00	285.00																		95.00								95.00				
H0490	004	0	1	01	01	H0490_004_0	7	4	Specialty Tier	1	4	010010	1	1	110000000010100000000111	31										31									31		31	14	31	14					388.26	25																							25																			25				25			25			
H0504	015	0	1	01	01	H0504_015_0	14	5	Specialty Tier	1	4	010010	1	1	100010110110001000000101				30		90	30		90	1			90							30		31		31	14													1309.00	33		33					1309.00	33		33							33																	33				33			33			
H0504	015	0	1	01	01	H0504_015_0	14	1	Preferred Generic	3	4	001000	3	2	000010110110001000000100				30		90	30		90	1			90							30		31													5.00		10.00						5.00		15.00								10.00																		5.00					5.00					1		
H0504	015	0	1	01	01	H0504_015_0	14	4	Injectable Drugs	1	4	010010	1	1	100010110110001000000101				30		90	30		90	1			90							30		31		31	14													276.00	25		25					276.00	25		25							25																	25				25			25			
H0504	015	0	1	01	01	H0504_015_0	14	3	Non-Preferred Brand	1	4	100000	1	2	100010110110001000000001				30		90	30		90	1			90							30				31	14										80.00		160.00						80.00		240.00								160.00																		80.00								80.00				
H0504	015	0	1	01	01	H0504_015_0	14	2	Preferred Brand	1	4	000101	1	2	100010110110001000000101				30		90	30		90	1			90							30		31		31	14										40.00		80.00						40.00		120.00								80.00																		40.00					40.00			40.00				
H0504	015	0	1	01	01	H0504_015_0	14	1	Preferred Generic	1	4	001000	3	2	000010110110001000000100				30		90	30		90	1			90							30		31													5.00		10.00						5.00		15.00								10.00																		5.00					5.00							
H0504	017	0	1	01	01	H0504_017_0	12	1	Preferred Generic	1	4	001000	1	2	000010110110001000000100				30		90	30		90	1			90							30		31													6.00		12.00						6.00		18.00								12.00																		6.00					6.00							
H0504	017	0	1	01	01	H0504_017_0	12	2	Preferred Brand	1	4	000101	1	2	100010110110001000000101				30		90	30		90	1			90							30		31		31	14										45.00		90.00						45.00		135.00								90.00																		45.00					45.00			45.00				
H0504	017	0	1	01	01	H0504_017_0	12	4	Injectable Drugs	1	4	010010	1	1	100010110110001000000101				30		90	30		90	1			90							30		31		31	14													225.00	25		25					225.00	25		25							25																	25				25			25			
H0504	017	0	1	01	01	H0504_017_0	12	3	Non-Preferred Brand	1	4	100000	1	2	100010110110001000000001				30		90	30		90	1			90							30				31	14										90.00		180.00						90.00		270.00								180.00																		90.00								90.00				
H0504	017	0	1	01	01	H0504_017_0	12	5	Specialty Tier	1	4	010010	1	1	100010110110001000000101				30		90	30		90	1			90							30		31		31	14													1595.00	33		33					1595.00	33		33							33																	33				33			33			
H0504	017	0	1	01	01	H0504_017_0	12	1	Preferred Generic	3	4	001000	1	2	000010110110001000000100				30		90	30		90	1			90							30		31													6.00		12.00						6.00		18.00								12.00																		6.00					6.00					1		
H0504	021	0	1	01	01	H0504_021_0	15	2	Preferred Brand	1	4	000101	1	2	100010110110001000000101				30		90	30		90	1			90							30		31		31	14										35.00		70.00						35.00		105.00								70.00																		35.00					35.00			35.00				
H0504	021	0	1	01	01	H0504_021_0	15	1	Preferred Generic	1	4	001010	3	2	100010110110001000000101				30		90	30		90	1			90							30		31		31	14										0.00		0.00						0.00		0.00								0.00																		0.00					0.00			0.00				
H0504	021	0	1	01	01	H0504_021_0	15	4	Injectable Drugs	1	4	010010	1	1	100010110110001000000101				30		90	30		90	1			90							30		31		31	14													299.00	25		25					299.00	25		25							25																	25				25			25			
H0504	021	0	1	01	01	H0504_021_0	15	1	Preferred Generic	3	4	001010	3	2	100010110110001000000101				30		90	30		90	1			90							30		31		31	14										0.00		0.00						0.00		0.00								0.00																		0.00					0.00			0.00		1		
H0504	021	0	1	01	01	H0504_021_0	15	5	Specialty Tier	1	4	010010	1	1	100010110110001000000101				30		90	30		90	1			90							30		31		31	14													1436.00	33		33					1436.00	33		33							33																	33				33			33			
H0504	021	0	1	01	01	H0504_021_0	15	3	Non-Preferred Brand	1	4	100000	1	2	100010110110001000000001				30		90	30		90	1			90							30				31	14										70.00		140.00						70.00		210.00								140.00																		70.00								70.00				
H0504	026	0	1	01	01	H0504_026_0	10	1	Preferred Generic	3	4	001000	1	2	000010110110001000000100				30		90	30		90	1			90							30		31													6.00		12.00						6.00		18.00								12.00																		6.00					6.00					1		
H0504	026	0	1	01	01	H0504_026_0	10	5	Specialty Tier	1	4	010010	1	1	100010110110001000000101				30		90	30		90	1			90							30		31		31	14													1439.00	33		33					1439.00	33		33							33																	33				33			33			
H0504	026	0	1	01	01	H0504_026_0	10	4	Injectable Drugs	1	4	010010	1	1	100010110110001000000101				30		90	30		90	1			90							30		31		31	14													314.00	25		25					314.00	25		25							25																	25				25			25			
H0504	026	0	1	01	01	H0504_026_0	10	3	Non-Preferred Brand	1	4	100000	1	2	100010110110001000000001				30		90	30		90	1			90							30				31	14										90.00		180.00						90.00		270.00								180.00																		90.00								90.00				
H0504	026	0	1	01	01	H0504_026_0	10	2	Preferred Brand	1	4	000101	1	2	100010110110001000000101				30		90	30		90	1			90							30		31		31	14										45.00		90.00						45.00		135.00								90.00																		45.00					45.00			45.00				
H0504	026	0	1	01	01	H0504_026_0	10	1	Preferred Generic	1	4	001000	1	2	000010110110001000000100				30		90	30		90	1			90							30		31													6.00		12.00						6.00		18.00								12.00																		6.00					6.00							
H0504	027	0	1	01	01	H0504_027_0	11	3	Non-Preferred Brand	1	4	100000	1	2	100010110110001000000001				30		90	30		90	1			90							30				31	14										85.00		170.00						85.00		255.00								170.00																		85.00								85.00				
H0504	027	0	1	01	01	H0504_027_0	11	2	Preferred Brand	1	4	000101	1	2	100010110110001000000101				30		90	30		90	1			90							30		31		31	14										45.00		90.00						45.00		135.00								90.00																		45.00					45.00			45.00				
H0504	027	0	1	01	01	H0504_027_0	11	1	Preferred Generic	1	4	001000	3	2	000010110110001000000100				30		90	30		90	1			90							30		31													5.00		10.00						5.00		15.00								10.00																		5.00					5.00							
H0504	027	0	1	01	01	H0504_027_0	11	4	Injectable Drugs	1	4	010010	1	1	100010110110001000000101				30		90	30		90	1			90							30		31		31	14													274.00	25		25					274.00	25		25							25																	25				25			25			
H0504	027	0	1	01	01	H0504_027_0	11	5	Specialty Tier	1	4	010010	1	1	100010110110001000000101				30		90	30		90	1			90							30		31		31	14													1344.00	33		33					1344.00	33		33							33																	33				33			33			
H0504	028	0	1	01	01	H0504_028_0	12	4	Injectable Drugs	1	4	010010	1	1	100010110110001000000101				30		90	30		90	1			90							30		31		31	14													274.00	25		25					274.00	25		25							25																	25				25			25			
H0504	028	0	1	01	01	H0504_028_0	12	5	Specialty Tier	1	4	010010	1	1	100010110110001000000101				30		90	30		90	1			90							30		31		31	14													1344.00	33		33					1344.00	33		33							33																	33				33			33			
H0504	028	0	1	01	01	H0504_028_0	12	1	Preferred Generic	3	4	001000	3	2	000010110110001000000100				30		90	30		90	1			90							30		31													5.00		10.00						5.00		15.00								10.00																		5.00					5.00					1		
H0504	028	0	1	01	01	H0504_028_0	12	3	Non-Preferred Brand	1	4	100000	1	2	100010110110001000000001				30		90	30		90	1			90							30				31	14										85.00		170.00						85.00		255.00								170.00																		85.00								85.00				
H0504	028	0	1	01	01	H0504_028_0	12	1	Preferred Generic	1	4	001000	3	2	000010110110001000000100				30		90	30		90	1			90							30		31													5.00		10.00						5.00		15.00								10.00																		5.00					5.00							
H0504	028	0	1	01	01	H0504_028_0	12	2	Preferred Brand	1	4	000101	1	2	100010110110001000000101				30		90	30		90	1			90							30		31		31	14										45.00		90.00						45.00		135.00								90.00																		45.00					45.00			45.00				
H0504	029	0	1	01	01	H0504_029_0	11	1	Preferred Generic	1	4	001000	3	2	000010110110001000000100				30		90	30		90	1			90							30		31													5.00		10.00						5.00		15.00								10.00																		5.00					5.00							
H0504	029	0	1	01	01	H0504_029_0	11	2	Preferred Brand	1	4	000101	1	2	100010110110001000000101				30		90	30		90	1			90							30		31		31	14										45.00		90.00						45.00		135.00								90.00																		45.00					45.00			45.00				
H0504	029	0	1	01	01	H0504_029_0	11	3	Non-Preferred Brand	1	4	100000	1	2	100010110110001000000001				30		90	30		90	1			90							30				31	14										85.00		170.00						85.00		255.00								170.00																		85.00								85.00				
H0504	029	0	1	01	01	H0504_029_0	11	5	Specialty Tier	1	4	010010	1	1	100010110110001000000101				30		90	30		90	1			90							30		31		31	14													1344.00	33		33					1344.00	33		33							33																	33				33			33			
H0504	029	0	1	01	01	H0504_029_0	11	4	Injectable Drugs	1	4	010010	1	1	100010110110001000000101				30		90	30		90	1			90							30		31		31	14													274.00	25		25					274.00	25		25							25																	25				25			25			
H0504	029	0	1	01	01	H0504_029_0	11	1	Preferred Generic	3	4	001000	3	2	000010110110001000000100				30		90	30		90	1			90							30		31													5.00		10.00						5.00		15.00								10.00																		5.00					5.00					1		
H0523	002	0	1	01	01	H0523_002_0	6	1	Preferred Generic	3	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					7.00	14.00	21.00																													7.00	14.00	14.00					7.00	14.00	21.00					7.00				7.00					1		
H0523	002	0	1	01	01	H0523_002_0	6	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					319.19	33	33	33																												33	33	33					33	33	33				33			33			33			
H0523	002	0	1	01	01	H0523_002_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H0523	002	0	1	01	01	H0523_002_0	6	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					7.00	14.00	21.00																													7.00	14.00	14.00					7.00	14.00	21.00					7.00				7.00							
H0523	002	0	1	01	01	H0523_002_0	6	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H0523	002	0	1	01	01	H0523_002_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H0523	022	0	1	01	01	H0523_022_0	7	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					245.25	33	33	33																												33	33	33					33	33	33				33			33			33			
H0523	022	0	1	01	01	H0523_022_0	7	1	Preferred Generic	3	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					7.00	14.00	21.00																													7.00	14.00	14.00					7.00	14.00	21.00					7.00				7.00					1		
H0523	022	0	1	01	01	H0523_022_0	7	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H0523	022	0	1	01	01	H0523_022_0	7	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H0523	022	0	1	01	01	H0523_022_0	7	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H0523	022	0	1	01	01	H0523_022_0	7	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					7.00	14.00	21.00																													7.00	14.00	14.00					7.00	14.00	21.00					7.00				7.00							
H0523	031	0	1	01	01	H0523_031_0	7	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H0523	031	0	1	01	01	H0523_031_0	7	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H0523	031	0	1	01	01	H0523_031_0	7	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H0523	031	0	1	01	01	H0523_031_0	7	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					65.04	33	33	33																												33	33	33					33	33	33				33			33			33			
H0523	031	0	1	01	01	H0523_031_0	7	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					7.00	14.00	21.00																													7.00	14.00	14.00					7.00	14.00	21.00					7.00				7.00							
H0523	032	0	1	01	01	H0523_032_0	7	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					302.07	33	33	33																												33	33	33					33	33	33				33			33			33			
H0523	032	0	1	01	01	H0523_032_0	7	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H0523	032	0	1	01	01	H0523_032_0	7	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H0523	032	0	1	01	01	H0523_032_0	7	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					7.00	14.00	21.00																													7.00	14.00	14.00					7.00	14.00	21.00					7.00				7.00							
H0523	032	0	1	01	01	H0523_032_0	7	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H0523	052	0	1	01	01	H0523_052_0	7	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H0523	052	0	1	01	01	H0523_052_0	7	1	Preferred Generic	3	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					7.00	14.00	21.00																													7.00	14.00	14.00					7.00	14.00	21.00					7.00				7.00					1		
H0523	052	0	1	01	01	H0523_052_0	7	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					167.79	33	33	33																												33	33	33					33	33	33				33			33			33			
H0523	052	0	1	01	01	H0523_052_0	7	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H0523	052	0	1	01	01	H0523_052_0	7	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H0523	052	0	1	01	01	H0523_052_0	7	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					7.00	14.00	21.00																													7.00	14.00	14.00					7.00	14.00	21.00					7.00				7.00							
H0523	058	0	1	01	01	H0523_058_0	6	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					335.62	33	33	33																												33	33	33					33	33	33				33			33			33			
H0523	058	0	1	01	01	H0523_058_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H0523	058	0	1	01	01	H0523_058_0	6	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H0523	058	0	1	01	01	H0523_058_0	6	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					7.00	14.00	21.00																													7.00	14.00	14.00					7.00	14.00	21.00					7.00				7.00							
H0523	058	0	1	01	01	H0523_058_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H0524	002	0	2	01	01	H0524_002_0	5	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000100	30		100							2	30		100							30		31					8.00		24.00																						8.00		16.00																		8.00					8.00					1		
H0524	002	0	2	01	01	H0524_002_0	5	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		100							2	30		100							30		31					5.00		15.00																						5.00		10.00																		5.00					5.00					1		
H0524	002	0	2	01	01	H0524_002_0	5	6	Vaccines	1	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00												
H0524	002	0	2	01	01	H0524_002_0	5	5	Specialty Tier	1	4	100001	1	1	110100000010101000000001	30		100							2	30		100							30				31	14					398.00	25		25																					25		25																	25							25			
H0524	002	0	2	01	01	H0524_002_0	5	6	Vaccines	3	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00										1		
H0524	002	0	2	01	01	H0524_002_0	5	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		100							2	30		100							30				31	14		45.00		135.00																						45.00		90.00																		45.00								45.00				
H0524	002	0	2	01	01	H0524_002_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		100							2	30		100							30		31					8.00		24.00																						8.00		16.00																		8.00					8.00							
H0524	002	0	2	01	01	H0524_002_0	5	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		100							2	30		100							30		31					5.00		15.00																						5.00		10.00																		5.00					5.00							
H0524	002	0	2	01	01	H0524_002_0	5	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		100							2	30		100							30				31	14		65.00		195.00																						65.00		130.00																		65.00								65.00				
H0524	003	0	1	01	01	H0524_003_0	5	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		100							2	30		100							30		31					3.00		9.00																						3.00		6.00																		3.00					3.00							
H0524	003	0	1	01	01	H0524_003_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		100							2	30		100							30		31					7.00		21.00																						7.00		14.00																		7.00					7.00							
H0524	003	0	1	01	01	H0524_003_0	5	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		100							2	30		100							30				31	14		40.00		120.00																						40.00		80.00																		40.00								40.00				
H0524	003	0	1	01	01	H0524_003_0	5	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		100							2	30		100							30				31	14		60.00		180.00																						60.00		120.00																		60.00								60.00				
H0524	003	0	1	01	01	H0524_003_0	5	5	Specialty Tier	1	4	100001	1	1	110100000010101000000001	30		100							2	30		100							30				31	14					521.00	25		25																					25		25																	25							25			
H0524	003	0	1	01	01	H0524_003_0	5	6	Vaccines	1	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00												
H0524	003	0	1	01	01	H0524_003_0	5	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		100							2	30		100							30		31					3.00		9.00																						3.00		6.00																		3.00					3.00					1		
H0524	003	0	1	01	01	H0524_003_0	5	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000100	30		100							2	30		100							30		31					7.00		21.00																						7.00		14.00																		7.00					7.00					1		
H0524	003	0	1	01	01	H0524_003_0	5	6	Vaccines	3	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00										1		
H0524	008	0	1	01	01	H0524_008_0	5	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		100							2	30		100							30		31					5.00		15.00																						5.00		10.00																		5.00					5.00							
H0524	008	0	1	01	01	H0524_008_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		100							2	30		100							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00							
H0524	008	0	1	01	01	H0524_008_0	5	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		100							2	30		100							30				31	14		45.00		135.00																						45.00		90.00																		45.00								45.00				
H0524	008	0	1	01	01	H0524_008_0	5	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		100							2	30		100							30				31	14		65.00		195.00																						65.00		130.00																		65.00								65.00				
H0524	008	0	1	01	01	H0524_008_0	5	6	Vaccines	3	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00										1		
H0524	008	0	1	01	01	H0524_008_0	5	6	Vaccines	1	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00												
H0524	008	0	1	01	01	H0524_008_0	5	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		100							2	30		100							30		31					5.00		15.00																						5.00		10.00																		5.00					5.00					1		
H0524	008	0	1	01	01	H0524_008_0	5	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000100	30		100							2	30		100							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00					1		
H0524	008	0	1	01	01	H0524_008_0	5	5	Specialty Tier	1	4	100001	1	1	110100000010101000000001	30		100							2	30		100							30				31	14					469.00	25		25																					25		25																	25							25			
H0524	010	0	2	01	01	H0524_010_0	5	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		100							2	30		100							30				31	14		65.00		195.00																						65.00		130.00																		65.00								65.00				
H0524	010	0	2	01	01	H0524_010_0	5	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		100							2	30		100							30				31	14		45.00		135.00																						45.00		90.00																		45.00								45.00				
H0524	010	0	2	01	01	H0524_010_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		100							2	30		100							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00							
H0524	010	0	2	01	01	H0524_010_0	5	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		100							2	30		100							30		31					5.00		15.00																						5.00		10.00																		5.00					5.00							
H0524	010	0	2	01	01	H0524_010_0	5	6	Vaccines	3	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00										1		
H0524	010	0	2	01	01	H0524_010_0	5	6	Vaccines	1	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00												
H0524	010	0	2	01	01	H0524_010_0	5	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		100							2	30		100							30		31					5.00		15.00																						5.00		10.00																		5.00					5.00					1		
H0524	010	0	2	01	01	H0524_010_0	5	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000100	30		100							2	30		100							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00					1		
H0524	010	0	2	01	01	H0524_010_0	5	5	Specialty Tier	1	4	100001	1	1	110100000010101000000001	30		100							2	30		100							30				31	14					506.00	25		25																					25		25																	25							25			
H0524	013	0	1	01	01	H0524_013_0	5	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		100							2	30		100							30				31	14		65.00		195.00																						65.00		130.00																		65.00								65.00				
H0524	013	0	1	01	01	H0524_013_0	5	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		100							2	30		100							30				31	14		45.00		135.00																						45.00		90.00																		45.00								45.00				
H0524	013	0	1	01	01	H0524_013_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		100							2	30		100							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00							
H0524	013	0	1	01	01	H0524_013_0	5	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		100							2	30		100							30		31					5.00		15.00																						5.00		10.00																		5.00					5.00							
H0524	013	0	1	01	01	H0524_013_0	5	5	Specialty Tier	1	4	100001	1	1	110100000010101000000001	30		100							2	30		100							30				31	14					523.00	25		25																					25		25																	25							25			
H0524	013	0	1	01	01	H0524_013_0	5	6	Vaccines	3	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00										1		
H0524	013	0	1	01	01	H0524_013_0	5	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000100	30		100							2	30		100							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00					1		
H0524	013	0	1	01	01	H0524_013_0	5	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		100							2	30		100							30		31					5.00		15.00																						5.00		10.00																		5.00					5.00					1		
H0524	013	0	1	01	01	H0524_013_0	5	6	Vaccines	1	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00												
H0524	015	0	1	01	01	H0524_015_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		100							2	30		100							30		31					5.00		15.00																						5.00		10.00																		5.00					5.00							
H0524	015	0	1	01	01	H0524_015_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		100							2	30		100							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00							
H0524	015	0	1	01	01	H0524_015_0	8	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		100							2	30		100							30				31	14		45.00		135.00																						45.00		90.00																		45.00								45.00				
H0524	015	0	1	01	01	H0524_015_0	8	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		100							2	30		100							30				31	14		65.00		195.00																						65.00		130.00																		65.00								65.00				
H0524	015	0	1	01	01	H0524_015_0	8	6	Vaccines	3	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00										1		
H0524	015	0	1	01	01	H0524_015_0	8	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		100							2	30		100							30		31					5.00		15.00																						5.00		10.00																		5.00					5.00					1		
H0524	015	0	1	01	01	H0524_015_0	8	6	Vaccines	1	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00												
H0524	015	0	1	01	01	H0524_015_0	8	5	Specialty Tier	1	4	100001	1	1	110100000010101000000001	30		100							2	30		100							30				31	14					517.00	25		25																					25		25																	25							25			
H0524	015	0	1	01	01	H0524_015_0	8	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000100	30		100							2	30		100							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00					1		
H0524	029	0	1	01	01	H0524_029_0	5	1	Preferred Generic	1	3	001000		2	010100000010101000000100	30		100							2	30		100							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00							
H0524	029	0	1	01	01	H0524_029_0	5	2	Non-Preferred Generic	1	3	000100		2	010100000010101000000100	30		100							2	30		100							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00							
H0524	029	0	1	01	01	H0524_029_0	5	6	Vaccines	1	3	000001		2	110000000010000000000000	30																			30					1		0.00																																												0.00												
H0524	029	0	1	01	01	H0524_029_0	5	4	Non-Preferred Brand	1	3	100000		2	110100000010101000000001	30		100							2	30		100							30				31	14		95.00		285.00																						95.00		190.00																		95.00								95.00				
H0524	029	0	1	01	01	H0524_029_0	5	5	Specialty Tier	1	3	100001		1	110100000010101000000001	30		100							2	30		100							30				31	14					504.00	25		25																					25		25																	25							25			
H0524	029	0	1	01	01	H0524_029_0	5	3	Preferred Brand	1	3	000001		2	110100000010101000000001	30		100							2	30		100							30				31	14		45.00		135.00																						45.00		90.00																		45.00								45.00				
H0524	030	0	1	01	01	H0524_030_0	5	1	Preferred Generic	1	3	001000		2	010100000010101000000100	30		100							2	30		100							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00							
H0524	030	0	1	01	01	H0524_030_0	5	2	Non-Preferred Generic	1	3	000100		2	010100000010101000000100	30		100							2	30		100							30		31					12.00		36.00																						12.00		24.00																		12.00					12.00							
H0524	030	0	1	01	01	H0524_030_0	5	6	Vaccines	1	3	000001		2	110000000010000000000000	30																			30					1		0.00																																												0.00												
H0524	030	0	1	01	01	H0524_030_0	5	4	Non-Preferred Brand	1	3	100000		2	110100000010101000000001	30		100							2	30		100							30				31	14		95.00		285.00																						95.00		190.00																		95.00								95.00				
H0524	030	0	1	01	01	H0524_030_0	5	5	Specialty Tier	1	3	100001		1	110100000010101000000001	30		100							2	30		100							30				31	14					435.00	25		25																					25		25																	25							25			
H0524	030	0	1	01	01	H0524_030_0	5	3	Preferred Brand	1	3	000001		2	110100000010101000000001	30		100							2	30		100							30				31	14		45.00		135.00																						45.00		90.00																		45.00								45.00				
H0524	031	0	1	01	01	H0524_031_0	6	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		100							2	30		100							30		31					5.00		15.00																						5.00		10.00																		5.00					5.00					1		
H0524	031	0	1	01	01	H0524_031_0	6	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000100	30		100							2	30		100							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00					1		
H0524	031	0	1	01	01	H0524_031_0	6	6	Vaccines	3	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00										1		
H0524	031	0	1	01	01	H0524_031_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		100							2	30		100							30		31					5.00		15.00																						5.00		10.00																		5.00					5.00							
H0524	031	0	1	01	01	H0524_031_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		100							2	30		100							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00							
H0524	031	0	1	01	01	H0524_031_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		100							2	30		100							30				31	14		45.00		135.00																						45.00		90.00																		45.00								45.00				
H0524	031	0	1	01	01	H0524_031_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		100							2	30		100							30				31	14		65.00		195.00																						65.00		130.00																		65.00								65.00				
H0524	031	0	1	01	01	H0524_031_0	6	5	Specialty Tier	1	4	100001	1	1	110100000010101000000001	30		100							2	30		100							30				31	14					548.00	25		25																					25		25																	25							25			
H0524	031	0	1	01	01	H0524_031_0	6	6	Vaccines	1	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00												
H0524	032	0	1	01	01	H0524_032_0	5	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		100							2	30		100							30		31					5.00		15.00																						5.00		10.00																		5.00					5.00							
H0524	032	0	1	01	01	H0524_032_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		100							2	30		100							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00							
H0524	032	0	1	01	01	H0524_032_0	5	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		100							2	30		100							30				31	14		45.00		135.00																						45.00		90.00																		45.00								45.00				
H0524	032	0	1	01	01	H0524_032_0	5	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		100							2	30		100							30				31	14		65.00		195.00																						65.00		130.00																		65.00								65.00				
H0524	032	0	1	01	01	H0524_032_0	5	6	Vaccines	3	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00										1		
H0524	032	0	1	01	01	H0524_032_0	5	6	Vaccines	1	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00												
H0524	032	0	1	01	01	H0524_032_0	5	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		100							2	30		100							30		31					5.00		15.00																						5.00		10.00																		5.00					5.00					1		
H0524	032	0	1	01	01	H0524_032_0	5	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000100	30		100							2	30		100							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00					1		
H0524	032	0	1	01	01	H0524_032_0	5	5	Specialty Tier	1	4	100001	1	1	110100000010101000000001	30		100							2	30		100							30				31	14					417.00	25		25																					25		25																	25							25			
H0524	033	0	1	01	01	H0524_033_0	5	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		100							2	30		100							30		31					5.00		15.00																						5.00		10.00																		5.00					5.00							
H0524	033	0	1	01	01	H0524_033_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		100							2	30		100							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00							
H0524	033	0	1	01	01	H0524_033_0	5	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		100							2	30		100							30				31	14		45.00		135.00																						45.00		90.00																		45.00								45.00				
H0524	033	0	1	01	01	H0524_033_0	5	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		100							2	30		100							30				31	14		65.00		195.00																						65.00		130.00																		65.00								65.00				
H0524	033	0	1	01	01	H0524_033_0	5	6	Vaccines	3	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00										1		
H0524	033	0	1	01	01	H0524_033_0	5	6	Vaccines	1	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00												
H0524	033	0	1	01	01	H0524_033_0	5	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		100							2	30		100							30		31					5.00		15.00																						5.00		10.00																		5.00					5.00					1		
H0524	033	0	1	01	01	H0524_033_0	5	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000100	30		100							2	30		100							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00					1		
H0524	033	0	1	01	01	H0524_033_0	5	5	Specialty Tier	1	4	100001	1	1	110100000010101000000001	30		100							2	30		100							30				31	14					559.00	25		25																					25		25																	25							25			
H0524	034	0	1	01	01	H0524_034_0	5	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		100							2	30		100							30		31					5.00		15.00																						5.00		10.00																		5.00					5.00							
H0524	034	0	1	01	01	H0524_034_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		100							2	30		100							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00							
H0524	034	0	1	01	01	H0524_034_0	5	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		100							2	30		100							30				31	14		45.00		135.00																						45.00		90.00																		45.00								45.00				
H0524	034	0	1	01	01	H0524_034_0	5	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		100							2	30		100							30				31	14		65.00		195.00																						65.00		130.00																		65.00								65.00				
H0524	034	0	1	01	01	H0524_034_0	5	6	Vaccines	3	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00										1		
H0524	034	0	1	01	01	H0524_034_0	5	6	Vaccines	1	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00												
H0524	034	0	1	01	01	H0524_034_0	5	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		100							2	30		100							30		31					5.00		15.00																						5.00		10.00																		5.00					5.00					1		
H0524	034	0	1	01	01	H0524_034_0	5	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000100	30		100							2	30		100							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00					1		
H0524	034	0	1	01	01	H0524_034_0	5	5	Specialty Tier	1	4	100001	1	1	110100000010101000000001	30		100							2	30		100							30				31	14					640.00	25		25																					25		25																	25							25			
H0524	035	0	1	01	01	H0524_035_0	5	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		100							2	30		100							30		31					5.00		15.00																						5.00		10.00																		5.00					5.00							
H0524	035	0	1	01	01	H0524_035_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		100							2	30		100							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00							
H0524	035	0	1	01	01	H0524_035_0	5	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		100							2	30		100							30				31	14		45.00		135.00																						45.00		90.00																		45.00								45.00				
H0524	035	0	1	01	01	H0524_035_0	5	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		100							2	30		100							30				31	14		65.00		195.00																						65.00		130.00																		65.00								65.00				
H0524	035	0	1	01	01	H0524_035_0	5	6	Vaccines	3	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00										1		
H0524	035	0	1	01	01	H0524_035_0	5	6	Vaccines	1	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00												
H0524	035	0	1	01	01	H0524_035_0	5	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		100							2	30		100							30		31					5.00		15.00																						5.00		10.00																		5.00					5.00					1		
H0524	035	0	1	01	01	H0524_035_0	5	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000100	30		100							2	30		100							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00					1		
H0524	035	0	1	01	01	H0524_035_0	5	5	Specialty Tier	1	4	100001	1	1	110100000010101000000001	30		100							2	30		100							30				31	14					523.00	25		25																					25		25																	25							25			
H0524	036	0	1	01	01	H0524_036_0	5	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		100							2	30		100							30		31					5.00		15.00																						5.00		10.00																		5.00					5.00							
H0524	036	0	1	01	01	H0524_036_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		100							2	30		100							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00							
H0524	036	0	1	01	01	H0524_036_0	5	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		100							2	30		100							30				31	14		45.00		135.00																						45.00		90.00																		45.00								45.00				
H0524	036	0	1	01	01	H0524_036_0	5	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		100							2	30		100							30				31	14		65.00		195.00																						65.00		130.00																		65.00								65.00				
H0524	036	0	1	01	01	H0524_036_0	5	6	Vaccines	3	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00										1		
H0524	036	0	1	01	01	H0524_036_0	5	6	Vaccines	1	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00												
H0524	036	0	1	01	01	H0524_036_0	5	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		100							2	30		100							30		31					5.00		15.00																						5.00		10.00																		5.00					5.00					1		
H0524	036	0	1	01	01	H0524_036_0	5	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000100	30		100							2	30		100							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00					1		
H0524	036	0	1	01	01	H0524_036_0	5	5	Specialty Tier	1	4	100001	1	1	110100000010101000000001	30		100							2	30		100							30				31	14					774.00	25		25																					25		25																	25							25			
H0524	037	0	1	01	01	H0524_037_0	5	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		100							2	30		100							30		31					5.00		15.00																						5.00		10.00																		5.00					5.00							
H0524	037	0	1	01	01	H0524_037_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		100							2	30		100							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00							
H0524	037	0	1	01	01	H0524_037_0	5	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		100							2	30		100							30				31	14		45.00		135.00																						45.00		90.00																		45.00								45.00				
H0524	037	0	1	01	01	H0524_037_0	5	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		100							2	30		100							30				31	14		65.00		195.00																						65.00		130.00																		65.00								65.00				
H0524	037	0	1	01	01	H0524_037_0	5	6	Vaccines	3	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00										1		
H0524	037	0	1	01	01	H0524_037_0	5	6	Vaccines	1	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00												
H0524	037	0	1	01	01	H0524_037_0	5	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		100							2	30		100							30		31					5.00		15.00																						5.00		10.00																		5.00					5.00					1		
H0524	037	0	1	01	01	H0524_037_0	5	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000100	30		100							2	30		100							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00					1		
H0524	037	0	1	01	01	H0524_037_0	5	5	Specialty Tier	1	4	100001	1	1	110100000010101000000001	30		100							2	30		100							30				31	14					567.00	25		25																					25		25																	25							25			
H0524	038	0	1	01	01	H0524_038_0	5	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		100							2	30		100							30		31					5.00		15.00																						5.00		10.00																		5.00					5.00							
H0524	038	0	1	01	01	H0524_038_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		100							2	30		100							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00							
H0524	038	0	1	01	01	H0524_038_0	5	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		100							2	30		100							30				31	14		45.00		135.00																						45.00		90.00																		45.00								45.00				
H0524	038	0	1	01	01	H0524_038_0	5	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		100							2	30		100							30				31	14		65.00		195.00																						65.00		130.00																		65.00								65.00				
H0524	038	0	1	01	01	H0524_038_0	5	6	Vaccines	3	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00										1		
H0524	038	0	1	01	01	H0524_038_0	5	6	Vaccines	1	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00												
H0524	038	0	1	01	01	H0524_038_0	5	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		100							2	30		100							30		31					5.00		15.00																						5.00		10.00																		5.00					5.00					1		
H0524	038	0	1	01	01	H0524_038_0	5	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000100	30		100							2	30		100							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00					1		
H0524	038	0	1	01	01	H0524_038_0	5	5	Specialty Tier	1	4	100001	1	1	110100000010101000000001	30		100							2	30		100							30				31	14					664.00	25		25																					25		25																	25							25			
H0524	039	0	1	01	01	H0524_039_0	5	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		100							2	30		100							30				31	14		65.00		195.00																						65.00		130.00																		65.00								65.00				
H0524	039	0	1	01	01	H0524_039_0	5	5	Specialty Tier	1	4	100001	1	1	110100000010101000000001	30		100							2	30		100							30				31	14					586.00	25		25																					25		25																	25							25			
H0524	039	0	1	01	01	H0524_039_0	5	6	Vaccines	1	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00												
H0524	039	0	1	01	01	H0524_039_0	5	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		100							2	30		100							30		31					5.00		15.00																						5.00		10.00																		5.00					5.00					1		
H0524	039	0	1	01	01	H0524_039_0	5	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		100							2	30		100							30				31	14		45.00		135.00																						45.00		90.00																		45.00								45.00				
H0524	039	0	1	01	01	H0524_039_0	5	6	Vaccines	3	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00										1		
H0524	039	0	1	01	01	H0524_039_0	5	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		100							2	30		100							30		31					5.00		15.00																						5.00		10.00																		5.00					5.00							
H0524	039	0	1	01	01	H0524_039_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		100							2	30		100							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00							
H0524	039	0	1	01	01	H0524_039_0	5	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000100	30		100							2	30		100							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00					1		
H0524	040	0	1	01	01	H0524_040_0	5	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		100							2	30		100							30		31					5.00		15.00																						5.00		10.00																		5.00					5.00							
H0524	040	0	1	01	01	H0524_040_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		100							2	30		100							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00							
H0524	040	0	1	01	01	H0524_040_0	5	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		100							2	30		100							30				31	14		45.00		135.00																						45.00		90.00																		45.00								45.00				
H0524	040	0	1	01	01	H0524_040_0	5	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		100							2	30		100							30				31	14		65.00		195.00																						65.00		130.00																		65.00								65.00				
H0524	040	0	1	01	01	H0524_040_0	5	6	Vaccines	3	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00										1		
H0524	040	0	1	01	01	H0524_040_0	5	6	Vaccines	1	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00												
H0524	040	0	1	01	01	H0524_040_0	5	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		100							2	30		100							30		31					5.00		15.00																						5.00		10.00																		5.00					5.00					1		
H0524	040	0	1	01	01	H0524_040_0	5	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000100	30		100							2	30		100							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00					1		
H0524	040	0	1	01	01	H0524_040_0	5	5	Specialty Tier	1	4	100001	1	1	110100000010101000000001	30		100							2	30		100							30				31	14					433.00	25		25																					25		25																	25							25			
H0524	041	0	1	01	01	H0524_041_0	5	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		100							2	30		100							30		31					5.00		15.00																						5.00		10.00																		5.00					5.00							
H0524	041	0	1	01	01	H0524_041_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		100							2	30		100							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00							
H0524	041	0	1	01	01	H0524_041_0	5	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		100							2	30		100							30				31	14		45.00		135.00																						45.00		90.00																		45.00								45.00				
H0524	041	0	1	01	01	H0524_041_0	5	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		100							2	30		100							30				31	14		65.00		195.00																						65.00		130.00																		65.00								65.00				
H0524	041	0	1	01	01	H0524_041_0	5	5	Specialty Tier	1	4	100001	1	1	110100000010101000000001	30		100							2	30		100							30				31	14					579.00	25		25																					25		25																	25							25			
H0524	041	0	1	01	01	H0524_041_0	5	6	Vaccines	1	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00												
H0524	041	0	1	01	01	H0524_041_0	5	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		100							2	30		100							30		31					5.00		15.00																						5.00		10.00																		5.00					5.00					1		
H0524	041	0	1	01	01	H0524_041_0	5	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000100	30		100							2	30		100							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00					1		
H0524	041	0	1	01	01	H0524_041_0	5	6	Vaccines	3	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00										1		
H0524	042	0	1	01	01	H0524_042_0	5	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		100							2	30		100							30		31					5.00		15.00																						5.00		10.00																		5.00					5.00							
H0524	042	0	1	01	01	H0524_042_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		100							2	30		100							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00							
H0524	042	0	1	01	01	H0524_042_0	5	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		100							2	30		100							30				31	14		45.00		135.00																						45.00		90.00																		45.00								45.00				
H0524	042	0	1	01	01	H0524_042_0	5	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		100							2	30		100							30				31	14		65.00		195.00																						65.00		130.00																		65.00								65.00				
H0524	042	0	1	01	01	H0524_042_0	5	6	Vaccines	3	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00										1		
H0524	042	0	1	01	01	H0524_042_0	5	6	Vaccines	1	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00												
H0524	042	0	1	01	01	H0524_042_0	5	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		100							2	30		100							30		31					5.00		15.00																						5.00		10.00																		5.00					5.00					1		
H0524	042	0	1	01	01	H0524_042_0	5	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000100	30		100							2	30		100							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00					1		
H0524	042	0	1	01	01	H0524_042_0	5	5	Specialty Tier	1	4	100001	1	1	110100000010101000000001	30		100							2	30		100							30				31	14					610.00	25		25																					25		25																	25							25			
H0524	043	0	1	01	01	H0524_043_0	5	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000100	30		100							2	30		100							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00					1		
H0524	043	0	1	01	01	H0524_043_0	5	6	Vaccines	3	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00										1		
H0524	043	0	1	01	01	H0524_043_0	5	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		100							2	30		100							30		31					5.00		15.00																						5.00		10.00																		5.00					5.00					1		
H0524	043	0	1	01	01	H0524_043_0	5	6	Vaccines	1	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00												
H0524	043	0	1	01	01	H0524_043_0	5	5	Specialty Tier	1	4	100001	1	1	110100000010101000000001	30		100							2	30		100							30				31	14					533.00	25		25																					25		25																	25							25			
H0524	043	0	1	01	01	H0524_043_0	5	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		100							2	30		100							30				31	14		65.00		195.00																						65.00		130.00																		65.00								65.00				
H0524	043	0	1	01	01	H0524_043_0	5	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		100							2	30		100							30				31	14		45.00		135.00																						45.00		90.00																		45.00								45.00				
H0524	043	0	1	01	01	H0524_043_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		100							2	30		100							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00							
H0524	043	0	1	01	01	H0524_043_0	5	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		100							2	30		100							30		31					5.00		15.00																						5.00		10.00																		5.00					5.00							
H0524	046	0	1	01	01	H0524_046_0	5	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		100							2	30		100							30		31					5.00		15.00																						5.00		10.00																		5.00					5.00							
H0524	046	0	1	01	01	H0524_046_0	5	6	Vaccines	3	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00										1		
H0524	046	0	1	01	01	H0524_046_0	5	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000100	30		100							2	30		100							30		31					8.00		24.00																						8.00		16.00																		8.00					8.00					1		
H0524	046	0	1	01	01	H0524_046_0	5	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		100							2	30		100							30		31					5.00		15.00																						5.00		10.00																		5.00					5.00					1		
H0524	046	0	1	01	01	H0524_046_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		100							2	30		100							30		31					8.00		24.00																						8.00		16.00																		8.00					8.00							
H0524	046	0	1	01	01	H0524_046_0	5	5	Specialty Tier	1	4	100001	1	1	110100000010101000000001	30		100							2	30		100							30				31	14					616.00	25		25																					25		25																	25							25			
H0524	046	0	1	01	01	H0524_046_0	5	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		100							2	30		100							30				31	14		65.00		195.00																						65.00		130.00																		65.00								65.00				
H0524	046	0	1	01	01	H0524_046_0	5	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		100							2	30		100							30				31	14		45.00		135.00																						45.00		90.00																		45.00								45.00				
H0524	046	0	1	01	01	H0524_046_0	5	6	Vaccines	1	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00												
H0543	001	0	1	01	01	H0543_001_0	8	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					605.00	33		33																														33							33			33				33			33			
H0543	001	0	1	01	01	H0543_001_0	8	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H0543	001	0	1	01	01	H0543_001_0	8	2	Non-Preferred Generic	3	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00					1		
H0543	001	0	1	01	01	H0543_001_0	8	1	Preferred Generic	3	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00					1		
H0543	001	0	1	01	01	H0543_001_0	8	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H0543	001	0	1	01	01	H0543_001_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H0543	001	0	1	01	01	H0543_001_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H0543	004	0	1	01	01	H0543_004_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H0543	004	0	1	01	01	H0543_004_0	8	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H0543	004	0	1	01	01	H0543_004_0	8	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H0543	004	0	1	01	01	H0543_004_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H0543	004	0	1	01	01	H0543_004_0	8	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					599.00	33		33																														33							33			33				33			33			
H0543	007	0	1	01	01	H0543_007_0	8	2	Non-Preferred Generic	3	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00					1		
H0543	007	0	1	01	01	H0543_007_0	8	1	Preferred Generic	3	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00					1		
H0543	007	0	1	01	01	H0543_007_0	8	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H0543	007	0	1	01	01	H0543_007_0	8	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H0543	007	0	1	01	01	H0543_007_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H0543	007	0	1	01	01	H0543_007_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H0543	007	0	1	01	01	H0543_007_0	8	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					581.00	33		33																														33							33			33				33			33			
H0543	013	0	1	01	01	H0543_013_0	8	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H0543	013	0	1	01	01	H0543_013_0	8	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H0543	013	0	1	01	01	H0543_013_0	8	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					558.00	33		33																														33							33			33				33			33			
H0543	013	0	1	01	01	H0543_013_0	8	1	Preferred Generic	3	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00					1		
H0543	013	0	1	01	01	H0543_013_0	8	2	Non-Preferred Generic	3	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00					1		
H0543	013	0	1	01	01	H0543_013_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H0543	013	0	1	01	01	H0543_013_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H0543	019	0	1	01	01	H0543_019_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H0543	019	0	1	01	01	H0543_019_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H0543	019	0	1	01	01	H0543_019_0	8	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H0543	019	0	1	01	01	H0543_019_0	8	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H0543	019	0	1	01	01	H0543_019_0	8	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					549.00	33		33																														33							33			33				33			33			
H0543	022	0	1	01	01	H0543_022_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					7.00		21.00																															14.00							21.00				7.00					7.00							
H0543	022	0	1	01	01	H0543_022_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					4.00		12.00																															8.00							12.00				4.00					4.00							
H0543	022	0	1	01	01	H0543_022_0	8	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H0543	022	0	1	01	01	H0543_022_0	8	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H0543	022	0	1	01	01	H0543_022_0	8	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					754.00	33		33																														33							33			33				33			33			
H0543	028	0	1	01	01	H0543_028_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H0543	028	0	1	01	01	H0543_028_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H0543	028	0	1	01	01	H0543_028_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H0543	028	0	1	01	01	H0543_028_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					759.00	33		33																														33							33			33				33			33			
H0543	028	0	1	01	01	H0543_028_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H0543	029	0	1	01	01	H0543_029_0	7	1	Preferred Generic	1	3	001000		2	010100000010000001001100	31		90							1						90			90	31		31					5.00		15.00																															10.00							15.00				5.00					5.00							
H0543	029	0	1	01	01	H0543_029_0	7	2	Non-Preferred Generic	1	3	000100		2	010100000010000001001100	31		90							1						90			90	31		31					10.00		30.00																															20.00							30.00				10.00					10.00							
H0543	029	0	1	01	01	H0543_029_0	7	4	Non-Preferred Brand	1	3	100100		2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H0543	029	0	1	01	01	H0543_029_0	7	3	Preferred Brand	1	3	010001		2	110100000010000001001101	31		90							1						90			90	31		31		31	14		44.00		132.00																															122.00							132.00				44.00					44.00			44.00				
H0543	029	0	1	01	01	H0543_029_0	7	5	Specialty Tier	1	3	010010		1	110100000010000001001101	31		90							1						90			90	31		31		31	14					530.00	33		33																														33							33			33				33			33			
H0543	032	0	1	01	01	H0543_032_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H0543	032	0	1	01	01	H0543_032_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H0543	032	0	1	01	01	H0543_032_0	8	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H0543	032	0	1	01	01	H0543_032_0	8	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H0543	032	0	1	01	01	H0543_032_0	8	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					458.00	33		33																														33							33			33				33			33			
H0543	035	0	1	01	01	H0543_035_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					381.00	33		33																														33							33			33				33			33			
H0543	035	0	1	01	01	H0543_035_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		92.00		276.00																															266.00							276.00				92.00					92.00			92.00				
H0543	035	0	1	01	01	H0543_035_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		44.00		132.00																															122.00							132.00				44.00					44.00			44.00				
H0543	035	0	1	01	01	H0543_035_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H0543	035	0	1	01	01	H0543_035_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H0543	036	0	1	01	01	H0543_036_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H0543	036	0	1	01	01	H0543_036_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H0543	036	0	1	01	01	H0543_036_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H0543	036	0	1	01	01	H0543_036_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H0543	036	0	1	01	01	H0543_036_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					517.00	33		33																														33							33			33				33			33			
H0543	060	0	1	01	01	H0543_060_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H0543	060	0	1	01	01	H0543_060_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H0543	060	0	1	01	01	H0543_060_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		42.00		126.00																															116.00							126.00				42.00					42.00			42.00				
H0543	060	0	1	01	01	H0543_060_0	7	2	Non-Preferred Generic	3	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00					1		
H0543	060	0	1	01	01	H0543_060_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					553.00	33		33																														33							33			33				33			33			
H0543	060	0	1	01	01	H0543_060_0	7	1	Preferred Generic	3	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00					1		
H0543	060	0	1	01	01	H0543_060_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		88.00		264.00																															254.00							264.00				88.00					88.00			88.00				
H0543	070	0	1	01	01	H0543_070_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					5.00		15.00																															10.00							15.00				5.00					5.00							
H0543	070	0	1	01	01	H0543_070_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					8.00		24.00																															16.00							24.00				8.00					8.00							
H0543	070	0	1	01	01	H0543_070_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					534.00	33		33																														33							33			33				33			33			
H0543	070	0	1	01	01	H0543_070_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H0543	070	0	1	01	01	H0543_070_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H0543	085	0	1	01	01	H0543_085_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					5.00		15.00																															10.00							15.00				5.00					5.00							
H0543	085	0	1	01	01	H0543_085_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					8.00		24.00																															16.00							24.00				8.00					8.00							
H0543	085	0	1	01	01	H0543_085_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H0543	085	0	1	01	01	H0543_085_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H0543	085	0	1	01	01	H0543_085_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					522.00	33		33																														33							33			33				33			33			
H0543	086	0	1	01	01	H0543_086_0	7	1	Preferred Generic	1	3	001000		2	010100000010000001001100	31		90							1						90			90	31		31					8.00		24.00																															16.00							24.00				8.00					8.00							
H0543	086	0	1	01	01	H0543_086_0	7	2	Non-Preferred Generic	1	3	000100		2	010100000010000001001100	31		90							1						90			90	31		31					12.00		36.00																															24.00							36.00				12.00					12.00							
H0543	086	0	1	01	01	H0543_086_0	7	3	Preferred Brand	1	3	010001		2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H0543	086	0	1	01	01	H0543_086_0	7	4	Non-Preferred Brand	1	3	100100		2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H0543	086	0	1	01	01	H0543_086_0	7	5	Specialty Tier	1	3	010010		1	110100000010000001001101	31		90							1						90			90	31		31		31	14					477.00	33		33																														33							33			33				33			33			
H0543	089	0	1	01	01	H0543_089_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H0543	089	0	1	01	01	H0543_089_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H0543	089	0	1	01	01	H0543_089_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H0543	089	0	1	01	01	H0543_089_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H0543	089	0	1	01	01	H0543_089_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					669.00	33		33																														33							33			33				33			33			
H0543	125	0	1	01	01	H0543_125_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					4.00		12.00																															8.00							12.00				4.00					4.00							
H0543	125	0	1	01	01	H0543_125_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					7.00		21.00																															14.00							21.00				7.00					7.00							
H0543	125	0	1	01	01	H0543_125_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					510.00	33		33																														33							33			33				33			33			
H0543	125	0	1	01	01	H0543_125_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H0543	125	0	1	01	01	H0543_125_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H0543	138	0	1	01	01	H0543_138_0	8	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H0543	138	0	1	01	01	H0543_138_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00							
H0543	138	0	1	01	01	H0543_138_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					5.00		15.00																															10.00							15.00				5.00					5.00							
H0543	138	0	1	01	01	H0543_138_0	8	2	Non-Preferred Generic	3	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					5.00		15.00																															10.00							15.00				5.00					5.00					1		
H0543	138	0	1	01	01	H0543_138_0	8	1	Preferred Generic	3	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00					1		
H0543	138	0	1	01	01	H0543_138_0	8	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					510.00	33		33																														33							33			33				33			33			
H0543	138	0	1	01	01	H0543_138_0	8	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		92.00		276.00																															266.00							276.00				92.00					92.00			92.00				
H0543	140	0	1	01	01	H0543_140_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H0543	140	0	1	01	01	H0543_140_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H0543	140	0	1	01	01	H0543_140_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H0543	140	0	1	01	01	H0543_140_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H0543	140	0	1	01	01	H0543_140_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					649.00	33		33																														33							33			33				33			33			
H0543	142	0	1	01	01	H0543_142_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H0543	142	0	1	01	01	H0543_142_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H0543	142	0	1	01	01	H0543_142_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H0543	142	0	1	01	01	H0543_142_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H0543	142	0	1	01	01	H0543_142_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					635.00	33		33																														33							33			33				33			33			
H0543	144	0	1	01	01	H0543_144_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00							
H0543	144	0	1	01	01	H0543_144_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					5.00		15.00																															10.00							15.00				5.00					5.00							
H0543	144	0	1	01	01	H0543_144_0	8	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H0543	144	0	1	01	01	H0543_144_0	8	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		92.00		276.00																															266.00							276.00				92.00					92.00			92.00				
H0543	144	0	1	01	01	H0543_144_0	8	1	Preferred Generic	3	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00					1		
H0543	144	0	1	01	01	H0543_144_0	8	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					508.00	33		33																														33							33			33				33			33			
H0543	144	0	1	01	01	H0543_144_0	8	2	Non-Preferred Generic	3	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					5.00		15.00																															10.00							15.00				5.00					5.00					1		
H0543	145	0	1	01	01	H0543_145_0	8	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H0543	145	0	1	01	01	H0543_145_0	8	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H0543	145	0	1	01	01	H0543_145_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H0543	145	0	1	01	01	H0543_145_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H0543	145	0	1	01	01	H0543_145_0	8	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					372.00	33		33																														33							33			33				33			33			
H0543	145	0	1	01	01	H0543_145_0	8	1	Preferred Generic	3	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00					1		
H0543	145	0	1	01	01	H0543_145_0	8	2	Non-Preferred Generic	3	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00					1		
H0543	146	0	1	01	01	H0543_146_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H0543	146	0	1	01	01	H0543_146_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H0543	146	0	1	01	01	H0543_146_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					511.00	33		33																														33							33			33				33			33			
H0543	146	0	1	01	01	H0543_146_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					4.00		12.00																															8.00							12.00				4.00					4.00							
H0543	146	0	1	01	01	H0543_146_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					7.00		21.00																															14.00							21.00				7.00					7.00							
H0543	147	0	1	01	01	H0543_147_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H0543	147	0	1	01	01	H0543_147_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					4.00		12.00																															8.00							12.00				4.00					4.00							
H0543	147	0	1	01	01	H0543_147_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					517.00	33		33																														33							33			33				33			33			
H0543	147	0	1	01	01	H0543_147_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H0543	147	0	1	01	01	H0543_147_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					7.00		21.00																															14.00							21.00				7.00					7.00							
H0543	148	0	1	01	01	H0543_148_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H0543	148	0	1	01	01	H0543_148_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					7.00		21.00																															14.00							21.00				7.00					7.00							
H0543	148	0	1	01	01	H0543_148_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					4.00		12.00																															8.00							12.00				4.00					4.00							
H0543	148	0	1	01	01	H0543_148_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H0543	148	0	1	01	01	H0543_148_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					503.00	33		33																														33							33			33				33			33			
H0543	149	0	1	01	01	H0543_149_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H0543	149	0	1	01	01	H0543_149_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					491.00	33		33																														33							33			33				33			33			
H0543	149	0	1	01	01	H0543_149_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					7.00		21.00																															14.00							21.00				7.00					7.00							
H0543	149	0	1	01	01	H0543_149_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H0543	149	0	1	01	01	H0543_149_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H0543	150	0	1	01	01	H0543_150_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					4.00		12.00																															8.00							12.00				4.00					4.00							
H0543	150	0	1	01	01	H0543_150_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					7.00		21.00																															14.00							21.00				7.00					7.00							
H0543	150	0	1	01	01	H0543_150_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					503.00	33		33																														33							33			33				33			33			
H0543	150	0	1	01	01	H0543_150_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H0543	150	0	1	01	01	H0543_150_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H0543	151	0	1	01	01	H0543_151_0	8	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					605.00	33		33																														33							33			33				33			33			
H0543	151	0	1	01	01	H0543_151_0	8	1	Preferred Generic	3	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00					1		
H0543	151	0	1	01	01	H0543_151_0	8	2	Non-Preferred Generic	3	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					5.00		15.00																															10.00							15.00				5.00					5.00					1		
H0543	151	0	1	01	01	H0543_151_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					5.00		15.00																															10.00							15.00				5.00					5.00							
H0543	151	0	1	01	01	H0543_151_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00							
H0543	151	0	1	01	01	H0543_151_0	8	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H0543	151	0	1	01	01	H0543_151_0	8	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		92.00		276.00																															266.00							276.00				92.00					92.00			92.00				
H0543	152	0	1	01	01	H0543_152_0	8	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					372.00	33		33																														33							33			33				33			33			
H0543	152	0	1	01	01	H0543_152_0	8	2	Non-Preferred Generic	3	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					7.00		21.00																															14.00							21.00				7.00					7.00					1		
H0543	152	0	1	01	01	H0543_152_0	8	1	Preferred Generic	3	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					4.00		12.00																															8.00							12.00				4.00					4.00					1		
H0543	152	0	1	01	01	H0543_152_0	8	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H0543	152	0	1	01	01	H0543_152_0	8	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H0543	152	0	1	01	01	H0543_152_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					7.00		21.00																															14.00							21.00				7.00					7.00							
H0543	152	0	1	01	01	H0543_152_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					4.00		12.00																															8.00							12.00				4.00					4.00							
H0544	002	0	1	01	01	H0544_002_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H0544	002	0	1	01	01	H0544_002_0	9	4	Non-Preferred Brand	1	4	100000	3	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H0544	002	0	1	01	01	H0544_002_0	9	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00				
H0544	002	0	1	01	01	H0544_002_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		25.00		75.00																								62.50																		25.00								25.00				
H0544	002	0	1	01	01	H0544_002_0	9	2	Non-Preferred Generic	1	4	000100	3	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H0544	002	0	1	01	01	H0544_002_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H0544	003	0	1	01	01	H0544_003_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H0544	003	0	1	01	01	H0544_003_0	9	3	Preferred Brand	1	4	000001	1	1	110100000010001000000001	30		90							1			90							30				31	14					4.12	25		25																							25																	25							25			
H0544	003	0	1	01	01	H0544_003_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H0544	003	0	1	01	01	H0544_003_0	9	6	Select Care Drugs	3	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00		1		
H0544	003	0	1	01	01	H0544_003_0	9	4	Non-Preferred Brand	1	4	100000	1	1	110100000010001000000001	30		90							1			90							30				31	14					3.09	25		25																							25																	25							25			
H0544	003	0	1	01	01	H0544_003_0	9	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H0544	003	0	1	01	01	H0544_003_0	9	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00				
H0544	003	0	1	01	01	H0544_003_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					3.30	25																							25																			25				25			25			
H0544	003	0	1	01	01	H0544_003_0	9	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H0544	004	0	1	01	01	H0544_004_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H0544	004	0	1	01	01	H0544_004_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H0544	004	0	1	01	01	H0544_004_0	9	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00				
H0544	004	0	1	01	01	H0544_004_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H0544	004	0	1	01	01	H0544_004_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		25.00		75.00																								62.50																		25.00								25.00				
H0544	004	0	1	01	01	H0544_004_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H0544	005	0	1	01	01	H0544_005_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H0544	005	0	1	01	01	H0544_005_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H0544	005	0	1	01	01	H0544_005_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H0544	005	0	1	01	01	H0544_005_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		25.00		75.00																								62.50																		25.00								25.00				
H0544	005	0	1	01	01	H0544_005_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H0544	005	0	1	01	01	H0544_005_0	9	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00				
H0544	007	0	1	01	01	H0544_007_0	9	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		10.00		30.00																								25.00																		10.00								10.00				
H0544	007	0	1	01	01	H0544_007_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		95.00		285.00																								237.50																		95.00								95.00				
H0544	007	0	1	01	01	H0544_007_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H0544	007	0	1	01	01	H0544_007_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					10.00		30.00																								25.00																		10.00					10.00							
H0544	007	0	1	01	01	H0544_007_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H0544	007	0	1	01	01	H0544_007_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		45.00		135.00																								112.50																		45.00								45.00				
H0544	008	0	1	01	01	H0544_008_0	8	4	Non-Preferred Brand	3	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00		2		
H0544	008	0	1	01	01	H0544_008_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H0544	008	0	1	01	01	H0544_008_0	8	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		29.00		87.00																								72.50																		29.00								29.00		2		
H0544	008	0	1	01	01	H0544_008_0	8	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		29.00		87.00																								72.50																		29.00								29.00				
H0544	008	0	1	01	01	H0544_008_0	8	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H0544	008	0	1	01	01	H0544_008_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H0544	008	0	1	01	01	H0544_008_0	8	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		10.00		30.00																								25.00																		10.00								10.00				
H0544	008	0	1	01	01	H0544_008_0	8	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H0544	008	0	1	01	01	H0544_008_0	8	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00					1		
H0544	008	0	1	01	01	H0544_008_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H0544	010	0	1	01	01	H0544_010_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H0544	010	0	1	01	01	H0544_010_0	10	6	Select Care Drugs	3	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00		1		
H0544	010	0	1	01	01	H0544_010_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H0544	010	0	1	01	01	H0544_010_0	10	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		29.00		87.00																								72.50																		29.00								29.00				
H0544	010	0	1	01	01	H0544_010_0	10	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H0544	010	0	1	01	01	H0544_010_0	10	4	Non-Preferred Brand	3	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00		2		
H0544	010	0	1	01	01	H0544_010_0	10	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00				
H0544	010	0	1	01	01	H0544_010_0	10	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H0544	010	0	1	01	01	H0544_010_0	10	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00					1		
H0544	010	0	1	01	01	H0544_010_0	10	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		29.00		87.00																								72.50																		29.00								29.00		2		
H0544	010	0	1	01	01	H0544_010_0	10	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H0544	012	0	1	01	01	H0544_012_0	8	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H0544	012	0	1	01	01	H0544_012_0	8	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		30.00		90.00																								75.00																		30.00								30.00				
H0544	012	0	1	01	01	H0544_012_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H0544	012	0	1	01	01	H0544_012_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H0544	012	0	1	01	01	H0544_012_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H0544	012	0	1	01	01	H0544_012_0	8	4	Non-Preferred Brand	3	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00		2		
H0544	012	0	1	01	01	H0544_012_0	8	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		30.00		90.00																								75.00																		30.00								30.00		2		
H0544	012	0	1	01	01	H0544_012_0	8	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00					1		
H0544	012	0	1	01	01	H0544_012_0	8	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		10.00		30.00																								25.00																		10.00								10.00				
H0544	012	0	1	01	01	H0544_012_0	8	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H0544	013	0	1	01	01	H0544_013_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		25.00		75.00																								62.50																		25.00								25.00				
H0544	013	0	1	01	01	H0544_013_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H0544	013	0	1	01	01	H0544_013_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H0544	013	0	1	01	01	H0544_013_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H0544	013	0	1	01	01	H0544_013_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H0544	013	0	1	01	01	H0544_013_0	9	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00				
H0544	014	0	1	01	01	H0544_014_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		25.00		75.00																								62.50																		25.00								25.00				
H0544	014	0	1	01	01	H0544_014_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H0544	014	0	1	01	01	H0544_014_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H0544	014	0	1	01	01	H0544_014_0	9	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00				
H0544	014	0	1	01	01	H0544_014_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H0544	014	0	1	01	01	H0544_014_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H0544	015	0	1	01	01	H0544_015_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H0544	015	0	1	01	01	H0544_015_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H0544	015	0	1	01	01	H0544_015_0	8	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00				
H0544	015	0	1	01	01	H0544_015_0	8	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H0544	015	0	1	01	01	H0544_015_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H0544	015	0	1	01	01	H0544_015_0	8	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		25.00		75.00																								62.50																		25.00								25.00				
H0544	019	0	1	01	01	H0544_019_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H0544	019	0	1	01	01	H0544_019_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H0544	019	0	1	01	01	H0544_019_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		29.00		87.00																								72.50																		29.00								29.00				
H0544	019	0	1	01	01	H0544_019_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H0544	019	0	1	01	01	H0544_019_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H0544	019	0	1	01	01	H0544_019_0	9	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00				
H0544	019	0	1	01	01	H0544_019_0	9	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H0544	019	0	1	01	01	H0544_019_0	9	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00					1		
H0544	019	0	1	01	01	H0544_019_0	9	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		29.00		87.00																								72.50																		29.00								29.00		2		
H0544	019	0	1	01	01	H0544_019_0	9	4	Non-Preferred Brand	3	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00		2		
H0544	019	0	1	01	01	H0544_019_0	9	6	Select Care Drugs	3	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00		1		
H0544	020	0	1	01	01	H0544_020_0	8	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								87.50																		35.00								35.00				
H0544	020	0	1	01	01	H0544_020_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H0544	020	0	1	01	01	H0544_020_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H0544	020	0	1	01	01	H0544_020_0	8	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H0544	020	0	1	01	01	H0544_020_0	8	4	Non-Preferred Brand	3	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00		2		
H0544	020	0	1	01	01	H0544_020_0	8	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00				
H0544	020	0	1	01	01	H0544_020_0	8	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H0544	020	0	1	01	01	H0544_020_0	8	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00					1		
H0544	020	0	1	01	01	H0544_020_0	8	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								87.50																		35.00								35.00		2		
H0544	020	0	1	01	01	H0544_020_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H0544	021	0	1	01	01	H0544_021_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		45.00		135.00																								112.50																		45.00								45.00				
H0544	021	0	1	01	01	H0544_021_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					10.00		30.00																								25.00																		10.00					10.00							
H0544	021	0	1	01	01	H0544_021_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H0544	021	0	1	01	01	H0544_021_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		95.00		285.00																								237.50																		95.00								95.00				
H0544	021	0	1	01	01	H0544_021_0	9	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		10.00		30.00																								25.00																		10.00								10.00				
H0544	021	0	1	01	01	H0544_021_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H0544	022	0	1	01	01	H0544_022_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H0544	022	0	1	01	01	H0544_022_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H0544	022	0	1	01	01	H0544_022_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		30.00		90.00																								75.00																		30.00								30.00				
H0544	022	0	1	01	01	H0544_022_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H0544	022	0	1	01	01	H0544_022_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H0544	022	0	1	01	01	H0544_022_0	9	6	Select Care Drugs	3	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00		1		
H0544	022	0	1	01	01	H0544_022_0	9	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H0544	022	0	1	01	01	H0544_022_0	9	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00					1		
H0544	022	0	1	01	01	H0544_022_0	9	4	Non-Preferred Brand	3	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00		2		
H0544	022	0	1	01	01	H0544_022_0	9	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		30.00		90.00																								75.00																		30.00								30.00		2		
H0544	022	0	1	01	01	H0544_022_0	9	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00				
H0544	024	0	1	01	01	H0544_024_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H0544	024	0	1	01	01	H0544_024_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H0544	024	0	1	01	01	H0544_024_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		30.00		90.00																								75.00																		30.00								30.00				
H0544	024	0	1	01	01	H0544_024_0	9	6	Select Care Drugs	3	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00		1		
H0544	024	0	1	01	01	H0544_024_0	9	4	Non-Preferred Brand	3	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00		2		
H0544	024	0	1	01	01	H0544_024_0	9	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		30.00		90.00																								75.00																		30.00								30.00		2		
H0544	024	0	1	01	01	H0544_024_0	9	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00					1		
H0544	024	0	1	01	01	H0544_024_0	9	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H0544	024	0	1	01	01	H0544_024_0	9	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00				
H0544	024	0	1	01	01	H0544_024_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H0544	024	0	1	01	01	H0544_024_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H0544	025	0	1	01	01	H0544_025_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H0544	025	0	1	01	01	H0544_025_0	8	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		30.00		90.00																								75.00																		30.00								30.00				
H0544	025	0	1	01	01	H0544_025_0	8	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H0544	025	0	1	01	01	H0544_025_0	8	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00					1		
H0544	025	0	1	01	01	H0544_025_0	8	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		30.00		90.00																								75.00																		30.00								30.00		2		
H0544	025	0	1	01	01	H0544_025_0	8	4	Non-Preferred Brand	3	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00		2		
H0544	025	0	1	01	01	H0544_025_0	8	6	Select Care Drugs	3	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00		1		
H0544	025	0	1	01	01	H0544_025_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H0544	025	0	1	01	01	H0544_025_0	8	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00				
H0544	025	0	1	01	01	H0544_025_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H0544	025	0	1	01	01	H0544_025_0	8	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H0544	027	0	1	01	01	H0544_027_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H0544	027	0	1	01	01	H0544_027_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H0544	027	0	1	01	01	H0544_027_0	8	4	Non-Preferred Brand	3	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00		2		
H0544	027	0	1	01	01	H0544_027_0	8	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		30.00		90.00																								75.00																		30.00								30.00		2		
H0544	027	0	1	01	01	H0544_027_0	8	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		30.00		90.00																								75.00																		30.00								30.00				
H0544	027	0	1	01	01	H0544_027_0	8	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H0544	027	0	1	01	01	H0544_027_0	8	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		10.00		30.00																								25.00																		10.00								10.00				
H0544	027	0	1	01	01	H0544_027_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H0544	027	0	1	01	01	H0544_027_0	8	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H0544	027	0	1	01	01	H0544_027_0	8	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00					1		
H0544	031	0	1	01	01	H0544_031_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H0544	031	0	1	01	01	H0544_031_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H0544	031	0	1	01	01	H0544_031_0	10	6	Select Care Drugs	3	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00		1		
H0544	031	0	1	01	01	H0544_031_0	10	4	Non-Preferred Brand	3	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00		2		
H0544	031	0	1	01	01	H0544_031_0	10	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		30.00		90.00																								75.00																		30.00								30.00		2		
H0544	031	0	1	01	01	H0544_031_0	10	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00					1		
H0544	031	0	1	01	01	H0544_031_0	10	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H0544	031	0	1	01	01	H0544_031_0	10	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00				
H0544	031	0	1	01	01	H0544_031_0	10	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H0544	031	0	1	01	01	H0544_031_0	10	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H0544	031	0	1	01	01	H0544_031_0	10	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		30.00		90.00																								75.00																		30.00								30.00				
H0544	032	0	1	01	01	H0544_032_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H0544	032	0	1	01	01	H0544_032_0	10	4	Non-Preferred Brand	3	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00		2		
H0544	032	0	1	01	01	H0544_032_0	10	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		30.00		90.00																								75.00																		30.00								30.00		2		
H0544	032	0	1	01	01	H0544_032_0	10	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00					1		
H0544	032	0	1	01	01	H0544_032_0	10	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H0544	032	0	1	01	01	H0544_032_0	10	6	Select Care Drugs	3	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00		1		
H0544	032	0	1	01	01	H0544_032_0	10	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H0544	032	0	1	01	01	H0544_032_0	10	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H0544	032	0	1	01	01	H0544_032_0	10	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		30.00		90.00																								75.00																		30.00								30.00				
H0544	032	0	1	01	01	H0544_032_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H0544	032	0	1	01	01	H0544_032_0	10	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00				
H0544	034	0	1	01	01	H0544_034_0	8	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		29.00		87.00																								72.50																		29.00								29.00				
H0544	034	0	1	01	01	H0544_034_0	8	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H0544	034	0	1	01	01	H0544_034_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H0544	034	0	1	01	01	H0544_034_0	8	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		10.00		30.00																								25.00																		10.00								10.00				
H0544	034	0	1	01	01	H0544_034_0	8	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H0544	034	0	1	01	01	H0544_034_0	8	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00					1		
H0544	034	0	1	01	01	H0544_034_0	8	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		29.00		87.00																								72.50																		29.00								29.00		2		
H0544	034	0	1	01	01	H0544_034_0	8	4	Non-Preferred Brand	3	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00		2		
H0544	034	0	1	01	01	H0544_034_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H0544	034	0	1	01	01	H0544_034_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H0544	035	0	1	01	01	H0544_035_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H0544	035	0	1	01	01	H0544_035_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H0544	035	0	1	01	01	H0544_035_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		29.00		87.00																								72.50																		29.00								29.00				
H0544	035	0	1	01	01	H0544_035_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H0544	035	0	1	01	01	H0544_035_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H0544	035	0	1	01	01	H0544_035_0	9	6	Select Care Drugs	3	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00		1		
H0544	035	0	1	01	01	H0544_035_0	9	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H0544	035	0	1	01	01	H0544_035_0	9	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00					1		
H0544	035	0	1	01	01	H0544_035_0	9	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		29.00		87.00																								72.50																		29.00								29.00		2		
H0544	035	0	1	01	01	H0544_035_0	9	4	Non-Preferred Brand	3	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00		2		
H0544	035	0	1	01	01	H0544_035_0	9	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00				
H0544	036	0	1	01	01	H0544_036_0	10	6	Select Care Drugs	3	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00		1		
H0544	036	0	1	01	01	H0544_036_0	10	4	Non-Preferred Brand	3	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00		2		
H0544	036	0	1	01	01	H0544_036_0	10	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		30.00		90.00																								75.00																		30.00								30.00		2		
H0544	036	0	1	01	01	H0544_036_0	10	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00					1		
H0544	036	0	1	01	01	H0544_036_0	10	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H0544	036	0	1	01	01	H0544_036_0	10	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00				
H0544	036	0	1	01	01	H0544_036_0	10	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H0544	036	0	1	01	01	H0544_036_0	10	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H0544	036	0	1	01	01	H0544_036_0	10	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		30.00		90.00																								75.00																		30.00								30.00				
H0544	036	0	1	01	01	H0544_036_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H0544	036	0	1	01	01	H0544_036_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H0544	037	0	1	01	01	H0544_037_0	12	4	Non-Preferred Brand	3	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00		2		
H0544	037	0	1	01	01	H0544_037_0	12	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		30.00		90.00																								75.00																		30.00								30.00		2		
H0544	037	0	1	01	01	H0544_037_0	12	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00					1		
H0544	037	0	1	01	01	H0544_037_0	12	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H0544	037	0	1	01	01	H0544_037_0	12	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00				
H0544	037	0	1	01	01	H0544_037_0	12	6	Select Care Drugs	3	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00		1		
H0544	037	0	1	01	01	H0544_037_0	12	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H0544	037	0	1	01	01	H0544_037_0	12	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		30.00		90.00																								75.00																		30.00								30.00				
H0544	037	0	1	01	01	H0544_037_0	12	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H0544	037	0	1	01	01	H0544_037_0	12	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H0544	037	0	1	01	01	H0544_037_0	12	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H0544	038	0	1	01	01	H0544_038_0	11	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H0544	038	0	1	01	01	H0544_038_0	11	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H0544	038	0	1	01	01	H0544_038_0	11	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		29.00		87.00																								72.50																		29.00								29.00				
H0544	038	0	1	01	01	H0544_038_0	11	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H0544	038	0	1	01	01	H0544_038_0	11	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H0544	038	0	1	01	01	H0544_038_0	11	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00				
H0544	038	0	1	01	01	H0544_038_0	11	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H0544	038	0	1	01	01	H0544_038_0	11	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00					1		
H0544	038	0	1	01	01	H0544_038_0	11	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		29.00		87.00																								72.50																		29.00								29.00		2		
H0544	038	0	1	01	01	H0544_038_0	11	4	Non-Preferred Brand	3	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00		2		
H0544	038	0	1	01	01	H0544_038_0	11	6	Select Care Drugs	3	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00		1		
H0544	039	0	1	01	01	H0544_039_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H0544	039	0	1	01	01	H0544_039_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					10.00		30.00																								25.00																		10.00					10.00							
H0544	039	0	1	01	01	H0544_039_0	9	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		10.00		30.00																								25.00																		10.00								10.00				
H0544	039	0	1	01	01	H0544_039_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H0544	039	0	1	01	01	H0544_039_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		95.00		285.00																								237.50																		95.00								95.00				
H0544	039	0	1	01	01	H0544_039_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		45.00		135.00																								112.50																		45.00								45.00				
H0544	040	0	1	01	01	H0544_040_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H0544	040	0	1	01	01	H0544_040_0	10	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		29.00		87.00																								72.50																		29.00								29.00				
H0544	040	0	1	01	01	H0544_040_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H0544	040	0	1	01	01	H0544_040_0	10	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H0544	040	0	1	01	01	H0544_040_0	10	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H0544	040	0	1	01	01	H0544_040_0	10	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00				
H0544	040	0	1	01	01	H0544_040_0	10	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H0544	040	0	1	01	01	H0544_040_0	10	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00					1		
H0544	040	0	1	01	01	H0544_040_0	10	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		29.00		87.00																								72.50																		29.00								29.00		2		
H0544	040	0	1	01	01	H0544_040_0	10	4	Non-Preferred Brand	3	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00		2		
H0544	040	0	1	01	01	H0544_040_0	10	6	Select Care Drugs	3	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00		1		
H0544	041	0	1	01	01	H0544_041_0	10	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					3.30	25																							25																			25				25			25			
H0544	041	0	1	01	01	H0544_041_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H0544	041	0	1	01	01	H0544_041_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H0544	041	0	1	01	01	H0544_041_0	10	3	Preferred Brand	1	4	000001	1	1	110100000010001000000001	30		90							1			90							30				31	14					4.12	25		25																							25																	25							25			
H0544	041	0	1	01	01	H0544_041_0	10	4	Non-Preferred Brand	1	4	100000	1	1	110100000010001000000001	30		90							1			90							30				31	14					3.09	25		25																							25																	25							25			
H0544	041	0	1	01	01	H0544_041_0	10	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H0544	041	0	1	01	01	H0544_041_0	10	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H0544	041	0	1	01	01	H0544_041_0	10	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00				
H0544	041	0	1	01	01	H0544_041_0	10	6	Select Care Drugs	3	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00		1		
H0544	043	0	1	01	01	H0544_043_0	9	4	Non-Preferred Brand	3	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00		2		
H0544	043	0	1	01	01	H0544_043_0	9	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		30.00		90.00																								75.00																		30.00								30.00		2		
H0544	043	0	1	01	01	H0544_043_0	9	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00					1		
H0544	043	0	1	01	01	H0544_043_0	9	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H0544	043	0	1	01	01	H0544_043_0	9	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		10.00		30.00																								25.00																		10.00								10.00				
H0544	043	0	1	01	01	H0544_043_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H0544	043	0	1	01	01	H0544_043_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H0544	043	0	1	01	01	H0544_043_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		30.00		90.00																								75.00																		30.00								30.00				
H0544	043	0	1	01	01	H0544_043_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H0544	043	0	1	01	01	H0544_043_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H0544	044	0	1	01	01	H0544_044_0	10	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H0544	044	0	1	01	01	H0544_044_0	10	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00				
H0544	044	0	1	01	01	H0544_044_0	10	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H0544	044	0	1	01	01	H0544_044_0	10	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H0544	044	0	1	01	01	H0544_044_0	10	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		30.00		90.00																								75.00																		30.00								30.00				
H0544	044	0	1	01	01	H0544_044_0	10	6	Select Care Drugs	3	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00		1		
H0544	044	0	1	01	01	H0544_044_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H0544	044	0	1	01	01	H0544_044_0	10	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00					1		
H0544	044	0	1	01	01	H0544_044_0	10	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		30.00		90.00																								75.00																		30.00								30.00		2		
H0544	044	0	1	01	01	H0544_044_0	10	4	Non-Preferred Brand	3	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00		2		
H0544	044	0	1	01	01	H0544_044_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H0544	045	0	1	01	01	H0544_045_0	10	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H0544	045	0	1	01	01	H0544_045_0	10	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00					1		
H0544	045	0	1	01	01	H0544_045_0	10	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		30.00		90.00																								75.00																		30.00								30.00		2		
H0544	045	0	1	01	01	H0544_045_0	10	4	Non-Preferred Brand	3	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00		2		
H0544	045	0	1	01	01	H0544_045_0	10	6	Select Care Drugs	3	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00		1		
H0544	045	0	1	01	01	H0544_045_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H0544	045	0	1	01	01	H0544_045_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H0544	045	0	1	01	01	H0544_045_0	10	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		30.00		90.00																								75.00																		30.00								30.00				
H0544	045	0	1	01	01	H0544_045_0	10	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H0544	045	0	1	01	01	H0544_045_0	10	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H0544	045	0	1	01	01	H0544_045_0	10	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00				
H0544	046	0	1	01	01	H0544_046_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H0544	046	0	1	01	01	H0544_046_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					10.00		30.00																								25.00																		10.00					10.00							
H0544	046	0	1	01	01	H0544_046_0	8	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		45.00		135.00																								112.50																		45.00								45.00				
H0544	046	0	1	01	01	H0544_046_0	8	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		95.00		285.00																								237.50																		95.00								95.00				
H0544	046	0	1	01	01	H0544_046_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H0544	046	0	1	01	01	H0544_046_0	8	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		10.00		30.00																								25.00																		10.00								10.00				
H0544	047	0	1	01	01	H0544_047_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					3.30	25																							25																			25				25			25			
H0544	047	0	1	01	01	H0544_047_0	9	6	Select Care Drugs	3	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00		1		
H0544	047	0	1	01	01	H0544_047_0	9	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H0544	047	0	1	01	01	H0544_047_0	9	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H0544	047	0	1	01	01	H0544_047_0	9	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00				
H0544	047	0	1	01	01	H0544_047_0	9	4	Non-Preferred Brand	1	4	100000	1	1	110100000010001000000001	30		90							1			90							30				31	14					3.09	25		25																							25																	25							25			
H0544	047	0	1	01	01	H0544_047_0	9	3	Preferred Brand	1	4	000001	1	1	110100000010001000000001	30		90							1			90							30				31	14					4.12	25		25																							25																	25							25			
H0544	047	0	1	01	01	H0544_047_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H0544	047	0	1	01	01	H0544_047_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H0545	001	0	1	01	01	H0545_001_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	31		90							2			90							31				31	14		29.00		87.00																								58.00																		29.00								29.00				
H0545	001	0	1	01	01	H0545_001_0	6	2	Non-Preferred Generic	1	4	000100	3	2	010100000010001000000100	31		90							2			90							31		31					12.00		36.00																								24.00																		12.00					12.00							
H0545	001	0	1	01	01	H0545_001_0	6	4	Non-Preferred Brand	1	4	100000	3	2	110100000010001000000001	31		90							2			90							31				31	14		67.00		201.00																								134.00																		67.00								67.00				
H0545	001	0	1	01	01	H0545_001_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	31																			31		31		31	14					739.00	25																																										25				25			25			
H0545	001	0	1	01	01	H0545_001_0	6	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	31		90							2			90							31		31					4.00		12.00																								8.00																		4.00					4.00					1		
H0545	001	0	1	01	01	H0545_001_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	31		90							2			90							31		31					4.00		12.00																								8.00																		4.00					4.00							
H0545	011	0	1	01	01	H0545_011_0	8	2	Non-Preferred Generic	1	4	000100	3	2	010100000010001000000100	31		90							2			90							31		31					12.00		36.00																								36.00																		12.00					12.00							
H0545	011	0	1	01	01	H0545_011_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	31		90							2			90							31		31					8.00		24.00																								24.00																		8.00					8.00							
H0545	011	0	1	01	01	H0545_011_0	8	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	31		90							2			90							31				31	14		45.00		135.00																								135.00																		45.00								45.00				
H0545	011	0	1	01	01	H0545_011_0	8	4	Non-Preferred Brand	1	4	100000	3	2	110100000010001000000001	31		90							2			90							31				31	14		70.00		210.00																								210.00																		70.00								70.00				
H0545	011	0	1	01	01	H0545_011_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	31																			31		31		31	14					1023.00	33																																										33				33			33			
H0545	012	0	1	01	01	H0545_012_0	5	2	Non-Preferred Generic	1	4	000100	3	2	010100000010001000000100	31		90							1			90							31		31					3.00		9.00																								9.00																		3.00					3.00							
H0545	012	0	1	01	01	H0545_012_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	31										31									31		31		31	14					461.00	30																							30																			30				30			30			
H0545	012	0	1	01	01	H0545_012_0	5	4	Non-Preferred Brand	1	4	100000	3	2	110100000010001000000001	31		90							2			90							31				31	14		40.00		120.00																								120.00																		40.00								40.00				
H0545	012	0	1	01	01	H0545_012_0	5	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	31		90							1			90							31				31	14		25.00		75.00																								75.00																		25.00								25.00				
H0545	012	0	1	01	01	H0545_012_0	5	2	Non-Preferred Generic	3	4	000100	3	2	010100000010001000000100	31		90							1			90							31		31					3.00		9.00																								9.00																		3.00					3.00					1		
H0545	012	0	1	01	01	H0545_012_0	5	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	31		90							1			90							31		31					0.00		0.00																								0.00																		0.00					0.00							
H0545	012	0	1	01	01	H0545_012_0	5	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	31		90							1			90							31		31					0.00		0.00																								0.00																		0.00					0.00					1		
H0562	009	0	1	01	01	H0562_009_0	3	1	Preferred Generic	1	4	001000	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				3.00	6.00	9.00																													3.00	6.00	6.00					3.00	6.00	9.00				3.00					3.00							
H0562	009	0	1	01	01	H0562_009_0	3	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				12.00	24.00	36.00																													12.00	24.00	24.00					12.00	24.00	36.00				12.00					12.00							
H0562	009	0	1	01	01	H0562_009_0	3	5	Specialty Tier	1	4	010010	1	1	111100000010000111111111	30	60	90							1				30	60	90	30	60	90	30		34	14	34	14					408.00	33	33	33																												33	33	33					33	33	33			33				33			33			
H0562	009	0	1	01	01	H0562_009_0	3	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		95.00	190.00	285.00																													95.00	190.00	275.00					95.00	190.00	285.00				95.00								95.00				
H0562	009	0	1	01	01	H0562_009_0	3	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		45.00	90.00	135.00																													45.00	90.00	125.00					45.00	90.00	135.00				45.00								45.00				
H0562	011	0	1	01	01	H0562_011_0	3	5	Specialty Tier	1	4	010010	1	1	111100000010000111111111	30	60	90							1				30	60	90	30	60	90	30		34	14	34	14					555.00	33	33	33																												33	33	33					33	33	33			33				33			33			
H0562	011	0	1	01	01	H0562_011_0	3	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		95.00	190.00	285.00																													95.00	190.00	275.00					95.00	190.00	285.00				95.00								95.00				
H0562	011	0	1	01	01	H0562_011_0	3	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		45.00	90.00	135.00																													45.00	90.00	125.00					45.00	90.00	135.00				45.00								45.00				
H0562	011	0	1	01	01	H0562_011_0	3	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				12.00	24.00	36.00																													12.00	24.00	24.00					12.00	24.00	36.00				12.00					12.00							
H0562	011	0	1	01	01	H0562_011_0	3	1	Preferred Generic	1	4	001000	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				3.00	6.00	9.00																													3.00	6.00	6.00					3.00	6.00	9.00				3.00					3.00							
H0562	012	0	1	01	01	H0562_012_0	3	1	Preferred Generic	3	4	001000	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				3.00	6.00	9.00																													3.00	6.00	6.00					3.00	6.00	9.00				3.00					3.00					1		
H0562	012	0	1	01	01	H0562_012_0	3	2	Non-Preferred Generic	3	4	000100	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				10.00	20.00	30.00																													10.00	20.00	20.00					10.00	20.00	30.00				10.00					10.00					1		
H0562	012	0	1	01	01	H0562_012_0	3	5	Specialty Tier	1	4	010010	1	1	111100000010000111111111	30	60	90							1				30	60	90	30	60	90	30		34	14	34	14					447.00	33	33	33																												33	33	33					33	33	33			33				33			33			
H0562	012	0	1	01	01	H0562_012_0	3	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		95.00	190.00	285.00																													95.00	190.00	275.00					95.00	190.00	285.00				95.00								95.00				
H0562	012	0	1	01	01	H0562_012_0	3	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		45.00	90.00	135.00																													45.00	90.00	125.00					45.00	90.00	135.00				45.00								45.00				
H0562	012	0	1	01	01	H0562_012_0	3	1	Preferred Generic	1	4	001000	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				3.00	6.00	9.00																													3.00	6.00	6.00					3.00	6.00	9.00				3.00					3.00							
H0562	012	0	1	01	01	H0562_012_0	3	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				10.00	20.00	30.00																													10.00	20.00	20.00					10.00	20.00	30.00				10.00					10.00							
H0562	017	0	1	01	01	H0562_017_0	4	1	Preferred Generic	1	4	001000	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				3.00	6.00	9.00																													3.00	6.00	6.00					3.00	6.00	9.00				3.00					3.00							
H0562	017	0	1	01	01	H0562_017_0	4	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				10.00	20.00	30.00																													10.00	20.00	20.00					10.00	20.00	30.00				10.00					10.00							
H0562	017	0	1	01	01	H0562_017_0	4	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		45.00	90.00	135.00																													45.00	90.00	125.00					45.00	90.00	135.00				45.00								45.00				
H0562	017	0	1	01	01	H0562_017_0	4	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		95.00	190.00	285.00																													95.00	190.00	275.00					95.00	190.00	285.00				95.00								95.00				
H0562	017	0	1	01	01	H0562_017_0	4	5	Specialty Tier	1	4	010010	1	1	111100000010000111111111	30	60	90							1				30	60	90	30	60	90	30		34	14	34	14					521.00	33	33	33																												33	33	33					33	33	33			33				33			33			
H0562	037	0	1	01	01	H0562_037_0	3	1	Preferred Generic	1	4	001000	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				5.00	10.00	15.00																													5.00	10.00	10.00					5.00	10.00	15.00				5.00					5.00							
H0562	037	0	1	01	01	H0562_037_0	3	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				15.00	30.00	45.00																													15.00	30.00	30.00					15.00	30.00	45.00				15.00					15.00							
H0562	037	0	1	01	01	H0562_037_0	3	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		45.00	90.00	135.00																													45.00	90.00	125.00					45.00	90.00	135.00				45.00								45.00				
H0562	037	0	1	01	01	H0562_037_0	3	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		95.00	190.00	285.00																													95.00	190.00	275.00					95.00	190.00	285.00				95.00								95.00				
H0562	037	0	1	01	01	H0562_037_0	3	5	Specialty Tier	1	4	010010	1	1	111100000010000111111111	30	60	90							1				30	60	90	30	60	90	30		34	14	34	14					452.00	33	33	33																												33	33	33					33	33	33			33				33			33			
H0562	039	0	1	01	01	H0562_039_0	3	1	Preferred Generic	1	4	001000	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				3.00	6.00	9.00																													3.00	6.00	6.00					3.00	6.00	9.00				3.00					3.00							
H0562	039	0	1	01	01	H0562_039_0	3	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				12.00	24.00	36.00																													12.00	24.00	24.00					12.00	24.00	36.00				12.00					12.00							
H0562	039	0	1	01	01	H0562_039_0	3	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		45.00	90.00	135.00																													45.00	90.00	125.00					45.00	90.00	135.00				45.00								45.00				
H0562	039	0	1	01	01	H0562_039_0	3	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		95.00	190.00	285.00																													95.00	190.00	275.00					95.00	190.00	285.00				95.00								95.00				
H0562	039	0	1	01	01	H0562_039_0	3	5	Specialty Tier	1	4	010010	1	1	111100000010000111111111	30	60	90							1				30	60	90	30	60	90	30		34	14	34	14					508.00	33	33	33																												33	33	33					33	33	33			33				33			33			
H0562	040	0	1	01	01	H0562_040_0	3	1	Preferred Generic	1	4	001000	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				5.00	10.00	15.00																													5.00	10.00	10.00					5.00	10.00	15.00				5.00					5.00							
H0562	040	0	1	01	01	H0562_040_0	3	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				15.00	30.00	45.00																													15.00	30.00	30.00					15.00	30.00	45.00				15.00					15.00							
H0562	040	0	1	01	01	H0562_040_0	3	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		45.00	90.00	135.00																													45.00	90.00	125.00					45.00	90.00	135.00				45.00								45.00				
H0562	040	0	1	01	01	H0562_040_0	3	2	Non-Preferred Generic	3	4	000100	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				15.00	30.00	45.00																													15.00	30.00	30.00					15.00	30.00	45.00				15.00					15.00					1		
H0562	040	0	1	01	01	H0562_040_0	3	5	Specialty Tier	1	4	010010	1	1	111100000010000111111111	30	60	90							1				30	60	90	30	60	90	30		34	14	34	14					330.00	33	33	33																												33	33	33					33	33	33			33				33			33			
H0562	040	0	1	01	01	H0562_040_0	3	1	Preferred Generic	3	4	001000	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				5.00	10.00	15.00																													5.00	10.00	10.00					5.00	10.00	15.00				5.00					5.00					1		
H0562	040	0	1	01	01	H0562_040_0	3	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		95.00	190.00	285.00																													95.00	190.00	275.00					95.00	190.00	285.00				95.00								95.00				
H0562	053	0	1	01	01	H0562_053_0	4	1	Preferred Generic	1	4	001000	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				3.00	6.00	9.00																													3.00	6.00	6.00					3.00	6.00	9.00				3.00					3.00							
H0562	053	0	1	01	01	H0562_053_0	4	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				12.00	24.00	36.00																													12.00	24.00	24.00					12.00	24.00	36.00				12.00					12.00							
H0562	053	0	1	01	01	H0562_053_0	4	5	Specialty Tier	1	4	010010	1	1	111100000010000111111111	30	60	90							1				30	60	90	30	60	90	30		34	14	34	14					292.00	33	33	33																												33	33	33					33	33	33			33				33			33			
H0562	053	0	1	01	01	H0562_053_0	4	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		95.00	190.00	285.00																													95.00	190.00	275.00					95.00	190.00	285.00				95.00								95.00				
H0562	053	0	1	01	01	H0562_053_0	4	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		45.00	90.00	135.00																													45.00	90.00	125.00					45.00	90.00	135.00				45.00								45.00				
H0562	068	0	1	01	01	H0562_068_0	3	1	Preferred Generic	1	4	001000	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				3.00	6.00	9.00																													3.00	6.00	6.00					3.00	6.00	9.00				3.00					3.00							
H0562	068	0	1	01	01	H0562_068_0	3	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				12.00	24.00	36.00																													12.00	24.00	24.00					12.00	24.00	36.00				12.00					12.00							
H0562	068	0	1	01	01	H0562_068_0	3	5	Specialty Tier	1	4	010010	1	1	111100000010000111111111	30	60	90							1				30	60	90	30	60	90	30		34	14	34	14					490.00	33	33	33																												33	33	33					33	33	33			33				33			33			
H0562	068	0	1	01	01	H0562_068_0	3	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		95.00	190.00	285.00																													95.00	190.00	275.00					95.00	190.00	285.00				95.00								95.00				
H0562	068	0	1	01	01	H0562_068_0	3	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		45.00	90.00	135.00																													45.00	90.00	125.00					45.00	90.00	135.00				45.00								45.00				
H0562	079	0	1	01	01	H0562_079_0	3	1	Preferred Generic	1	4	001000	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				0.00	0.00	0.00																													0.00	0.00	0.00					0.00	0.00	0.00				0.00					0.00							
H0562	079	0	1	01	01	H0562_079_0	3	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				15.00	30.00	45.00																													15.00	30.00	30.00					15.00	30.00	45.00				15.00					15.00							
H0562	079	0	1	01	01	H0562_079_0	3	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		45.00	90.00	135.00																													45.00	90.00	125.00					45.00	90.00	135.00				45.00								45.00				
H0562	079	0	1	01	01	H0562_079_0	3	2	Non-Preferred Generic	3	4	000100	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				15.00	30.00	45.00																													15.00	30.00	30.00					15.00	30.00	45.00				15.00					15.00					1		
H0562	079	0	1	01	01	H0562_079_0	3	5	Specialty Tier	1	4	010010	1	1	111100000010000111111111	30	60	90							1				30	60	90	30	60	90	30		34	14	34	14					451.00	33	33	33																												33	33	33					33	33	33			33				33			33			
H0562	079	0	1	01	01	H0562_079_0	3	1	Preferred Generic	3	4	001000	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				0.00	0.00	0.00																													0.00	0.00	0.00					0.00	0.00	0.00				0.00					0.00					1		
H0562	079	0	1	01	01	H0562_079_0	3	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		95.00	190.00	285.00																													95.00	190.00	275.00					95.00	190.00	285.00				95.00								95.00				
H0562	082	0	1	01	01	H0562_082_0	3	1	Preferred Generic	3	4	001000	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				3.00	6.00	9.00																													3.00	6.00	6.00					3.00	6.00	9.00				3.00					3.00					1		
H0562	082	0	1	01	01	H0562_082_0	3	1	Preferred Generic	1	4	001000	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				3.00	6.00	9.00																													3.00	6.00	6.00					3.00	6.00	9.00				3.00					3.00							
H0562	082	0	1	01	01	H0562_082_0	3	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				10.00	20.00	30.00																													10.00	20.00	20.00					10.00	20.00	30.00				10.00					10.00							
H0562	082	0	1	01	01	H0562_082_0	3	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		45.00	90.00	135.00																													45.00	90.00	125.00					45.00	90.00	135.00				45.00								45.00				
H0562	082	0	1	01	01	H0562_082_0	3	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		95.00	190.00	285.00																													95.00	190.00	275.00					95.00	190.00	285.00				95.00								95.00				
H0562	082	0	1	01	01	H0562_082_0	3	5	Specialty Tier	1	4	010010	1	1	111100000010000111111111	30	60	90							1				30	60	90	30	60	90	30		34	14	34	14					540.00	33	33	33																												33	33	33					33	33	33			33				33			33			
H0562	082	0	1	01	01	H0562_082_0	3	2	Non-Preferred Generic	3	4	000100	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				10.00	20.00	30.00																													10.00	20.00	20.00					10.00	20.00	30.00				10.00					10.00					1		
H0562	083	0	1	01	01	H0562_083_0	3	1	Preferred Generic	1	4	001000	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				3.00	6.00	9.00																													3.00	6.00	6.00					3.00	6.00	9.00				3.00					3.00							
H0562	083	0	1	01	01	H0562_083_0	3	2	Non-Preferred Generic	3	4	000100	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				10.00	20.00	30.00																													10.00	20.00	20.00					10.00	20.00	30.00				10.00					10.00					1		
H0562	083	0	1	01	01	H0562_083_0	3	1	Preferred Generic	3	4	001000	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				3.00	6.00	9.00																													3.00	6.00	6.00					3.00	6.00	9.00				3.00					3.00					1		
H0562	083	0	1	01	01	H0562_083_0	3	5	Specialty Tier	1	4	010010	1	1	111100000010000111111111	30	60	90							1				30	60	90	30	60	90	30		34	14	34	14					436.00	33	33	33																												33	33	33					33	33	33			33				33			33			
H0562	083	0	1	01	01	H0562_083_0	3	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		95.00	190.00	285.00																													95.00	190.00	275.00					95.00	190.00	285.00				95.00								95.00				
H0562	083	0	1	01	01	H0562_083_0	3	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		45.00	90.00	135.00																													45.00	90.00	125.00					45.00	90.00	135.00				45.00								45.00				
H0562	083	0	1	01	01	H0562_083_0	3	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				10.00	20.00	30.00																													10.00	20.00	20.00					10.00	20.00	30.00				10.00					10.00							
H0562	084	0	1	01	01	H0562_084_0	4	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		95.00	190.00	285.00																													95.00	190.00	275.00					95.00	190.00	285.00				95.00								95.00				
H0562	084	0	1	01	01	H0562_084_0	4	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		45.00	90.00	135.00																													45.00	90.00	125.00					45.00	90.00	135.00				45.00								45.00				
H0562	084	0	1	01	01	H0562_084_0	4	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				12.00	24.00	36.00																													12.00	24.00	24.00					12.00	24.00	36.00				12.00					12.00							
H0562	084	0	1	01	01	H0562_084_0	4	1	Preferred Generic	1	4	001000	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				3.00	6.00	9.00																													3.00	6.00	6.00					3.00	6.00	9.00				3.00					3.00							
H0562	084	0	1	01	01	H0562_084_0	4	5	Specialty Tier	1	4	010010	1	1	111100000010000111111111	30	60	90							1				30	60	90	30	60	90	30		34	14	34	14					567.00	33	33	33																												33	33	33					33	33	33			33				33			33			
H0562	085	0	1	01	01	H0562_085_0	3	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				10.00	20.00	30.00																													10.00	20.00	20.00					10.00	20.00	30.00				10.00					10.00							
H0562	085	0	1	01	01	H0562_085_0	3	1	Preferred Generic	1	4	001000	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				0.00	0.00	0.00																													0.00	0.00	0.00					0.00	0.00	0.00				0.00					0.00							
H0562	085	0	1	01	01	H0562_085_0	3	2	Non-Preferred Generic	3	4	000100	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				10.00	20.00	30.00																													10.00	20.00	20.00					10.00	20.00	30.00				10.00					10.00					1		
H0562	085	0	1	01	01	H0562_085_0	3	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		45.00	90.00	135.00																													45.00	90.00	125.00					45.00	90.00	135.00				45.00								45.00				
H0562	085	0	1	01	01	H0562_085_0	3	1	Preferred Generic	3	4	001000	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				0.00	0.00	0.00																													0.00	0.00	0.00					0.00	0.00	0.00				0.00					0.00					1		
H0562	085	0	1	01	01	H0562_085_0	3	5	Specialty Tier	1	4	010010	1	1	111100000010000111111111	30	60	90							1				30	60	90	30	60	90	30		34	14	34	14					605.00	33	33	33																												33	33	33					33	33	33			33				33			33			
H0562	085	0	1	01	01	H0562_085_0	3	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		95.00	190.00	285.00																													95.00	190.00	275.00					95.00	190.00	285.00				95.00								95.00				
H0562	086	0	1	01	01	H0562_086_0	5	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		95.00	190.00	285.00																													95.00	190.00	275.00					95.00	190.00	285.00				95.00								95.00				
H0562	086	0	1	01	01	H0562_086_0	5	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		45.00	90.00	135.00																													45.00	90.00	125.00					45.00	90.00	135.00				45.00								45.00				
H0562	086	0	1	01	01	H0562_086_0	5	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				10.00	20.00	30.00																													10.00	20.00	20.00					10.00	20.00	30.00				10.00					10.00							
H0562	086	0	1	01	01	H0562_086_0	5	1	Preferred Generic	1	4	001000	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				3.00	6.00	9.00																													3.00	6.00	6.00					3.00	6.00	9.00				3.00					3.00							
H0562	086	0	1	01	01	H0562_086_0	5	5	Specialty Tier	1	4	010010	1	1	111100000010000111111111	30	60	90							1				30	60	90	30	60	90	30		34	14	34	14					854.00	33	33	33																												33	33	33					33	33	33			33				33			33			
H0562	087	0	1	01	01	H0562_087_0	3	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		95.00	190.00	285.00																													95.00	190.00	275.00					95.00	190.00	285.00				95.00								95.00				
H0562	087	0	1	01	01	H0562_087_0	3	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		45.00	90.00	135.00																													45.00	90.00	125.00					45.00	90.00	135.00				45.00								45.00				
H0562	087	0	1	01	01	H0562_087_0	3	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				15.00	30.00	45.00																													15.00	30.00	30.00					15.00	30.00	45.00				15.00					15.00							
H0562	087	0	1	01	01	H0562_087_0	3	1	Preferred Generic	1	4	001000	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				3.00	6.00	9.00																													3.00	6.00	6.00					3.00	6.00	9.00				3.00					3.00							
H0562	087	0	1	01	01	H0562_087_0	3	5	Specialty Tier	1	4	010010	1	1	111100000010000111111111	30	60	90							1				30	60	90	30	60	90	30		34	14	34	14					573.00	33	33	33																												33	33	33					33	33	33			33				33			33			
H0562	088	0	1	01	01	H0562_088_0	4	1	Preferred Generic	1	4	001000	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				3.00	6.00	9.00																													3.00	6.00	6.00					3.00	6.00	9.00				3.00					3.00							
H0562	088	0	1	01	01	H0562_088_0	4	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				12.00	24.00	36.00																													12.00	24.00	24.00					12.00	24.00	36.00				12.00					12.00							
H0562	088	0	1	01	01	H0562_088_0	4	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		45.00	90.00	135.00																													45.00	90.00	125.00					45.00	90.00	135.00				45.00								45.00				
H0562	088	0	1	01	01	H0562_088_0	4	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		95.00	190.00	285.00																													95.00	190.00	275.00					95.00	190.00	285.00				95.00								95.00				
H0562	088	0	1	01	01	H0562_088_0	4	5	Specialty Tier	1	4	010010	1	1	111100000010000111111111	30	60	90							1				30	60	90	30	60	90	30		34	14	34	14					482.00	33	33	33																												33	33	33					33	33	33			33				33			33			
H0562	089	0	1	01	01	H0562_089_0	4	1	Preferred Generic	1	4	001000	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				3.00	6.00	9.00																													3.00	6.00	6.00					3.00	6.00	9.00				3.00					3.00							
H0562	089	0	1	01	01	H0562_089_0	4	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		95.00	190.00	285.00																													95.00	190.00	275.00					95.00	190.00	285.00				95.00								95.00				
H0562	089	0	1	01	01	H0562_089_0	4	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		45.00	90.00	135.00																													45.00	90.00	125.00					45.00	90.00	135.00				45.00								45.00				
H0562	089	0	1	01	01	H0562_089_0	4	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				15.00	30.00	45.00																													15.00	30.00	30.00					15.00	30.00	45.00				15.00					15.00							
H0562	089	0	1	01	01	H0562_089_0	4	5	Specialty Tier	1	4	010010	1	1	111100000010000111111111	30	60	90							1				30	60	90	30	60	90	30		34	14	34	14					484.00	33	33	33																												33	33	33					33	33	33			33				33			33			
H0562	090	0	1	01	01	H0562_090_0	4	1	Preferred Generic	1	4	001000	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				3.00	6.00	9.00																													3.00	6.00	6.00					3.00	6.00	9.00				3.00					3.00							
H0562	090	0	1	01	01	H0562_090_0	4	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				10.00	20.00	30.00																													10.00	20.00	20.00					10.00	20.00	30.00				10.00					10.00							
H0562	090	0	1	01	01	H0562_090_0	4	5	Specialty Tier	1	4	010010	1	1	111100000010000111111111	30	60	90							1				30	60	90	30	60	90	30		34	14	34	14					451.00	33	33	33																												33	33	33					33	33	33			33				33			33			
H0562	090	0	1	01	01	H0562_090_0	4	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		95.00	190.00	285.00																													95.00	190.00	275.00					95.00	190.00	285.00				95.00								95.00				
H0562	090	0	1	01	01	H0562_090_0	4	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		45.00	90.00	135.00																													45.00	90.00	125.00					45.00	90.00	135.00				45.00								45.00				
H0562	091	0	1	01	01	H0562_091_0	5	1	Preferred Generic	1	4	001000	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				5.00	10.00	15.00																													5.00	10.00	10.00					5.00	10.00	15.00				5.00					5.00							
H0562	091	0	1	01	01	H0562_091_0	5	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				15.00	30.00	45.00																													15.00	30.00	30.00					15.00	30.00	45.00				15.00					15.00							
H0562	091	0	1	01	01	H0562_091_0	5	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		45.00	90.00	135.00																													45.00	90.00	125.00					45.00	90.00	135.00				45.00								45.00				
H0562	091	0	1	01	01	H0562_091_0	5	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		95.00	190.00	285.00																													95.00	190.00	275.00					95.00	190.00	285.00				95.00								95.00				
H0562	091	0	1	01	01	H0562_091_0	5	5	Specialty Tier	1	4	010010	1	1	111100000010000111111111	30	60	90							1				30	60	90	30	60	90	30		34	14	34	14					436.00	33	33	33																												33	33	33					33	33	33			33				33			33			
H0562	092	0	1	01	01	H0562_092_0	8	2	Non-Preferred Generic	3	4	000100	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				10.00	20.00	30.00																													10.00	20.00	20.00					10.00	20.00	30.00				10.00					10.00					1		
H0562	092	0	1	01	01	H0562_092_0	8	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		95.00	190.00	285.00																													95.00	190.00	275.00					95.00	190.00	285.00				95.00								95.00				
H0562	092	0	1	01	01	H0562_092_0	8	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		45.00	90.00	135.00																													45.00	90.00	125.00					45.00	90.00	135.00				45.00								45.00				
H0562	092	0	1	01	01	H0562_092_0	8	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				10.00	20.00	30.00																													10.00	20.00	20.00					10.00	20.00	30.00				10.00					10.00							
H0562	092	0	1	01	01	H0562_092_0	8	5	Specialty Tier	1	4	010010	1	1	111100000010000111111111	30	60	90							1				30	60	90	30	60	90	30		34	14	34	14					541.00	33	33	33																												33	33	33					33	33	33			33				33			33			
H0562	092	0	1	01	01	H0562_092_0	8	1	Preferred Generic	3	4	001000	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				0.00	0.00	0.00																													0.00	0.00	0.00					0.00	0.00	0.00				0.00					0.00					1		
H0562	092	0	1	01	01	H0562_092_0	8	1	Preferred Generic	1	4	001000	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				0.00	0.00	0.00																													0.00	0.00	0.00					0.00	0.00	0.00				0.00					0.00							
H0562	093	0	1	01	01	H0562_093_0	6	1	Preferred Generic	1	4	001000	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				3.00	6.00	9.00																													3.00	6.00	6.00					3.00	6.00	9.00				3.00					3.00							
H0562	093	0	1	01	01	H0562_093_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				10.00	20.00	30.00																													10.00	20.00	20.00					10.00	20.00	30.00				10.00					10.00							
H0562	093	0	1	01	01	H0562_093_0	6	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		45.00	90.00	135.00																													45.00	90.00	125.00					45.00	90.00	135.00				45.00								45.00				
H0562	093	0	1	01	01	H0562_093_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		95.00	190.00	285.00																													95.00	190.00	275.00					95.00	190.00	285.00				95.00								95.00				
H0562	093	0	1	01	01	H0562_093_0	6	5	Specialty Tier	1	4	010010	1	1	111100000010000111111111	30	60	90							1				30	60	90	30	60	90	30		34	14	34	14					537.00	33	33	33																												33	33	33					33	33	33			33				33			33			
H0564	006	0	1	01	01	H0564_006_0	8	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					952.00	33																							33																			33				33			33			
H0564	006	0	1	01	01	H0564_006_0	8	5	Injectable Drugs	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					90.00	33	33	33																					33	33	33																	33				33			33			
H0564	006	0	1	01	01	H0564_006_0	8	4	Non-Preferred Brand	1	4	110000	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H0564	006	0	1	01	01	H0564_006_0	8	3	Preferred Brand	1	4	010001	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00					45.00			45.00				
H0564	006	0	1	01	01	H0564_006_0	8	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				4.00	8.00	12.00																						4.00	8.00	6.00																		4.00					4.00							
H0564	006	0	1	01	01	H0564_006_0	8	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				13.00	26.00	39.00																						13.00	26.00	19.50																		13.00					13.00							
H0564	006	0	1	01	01	H0564_006_0	8	2	Non-Preferred Generic	3	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				13.00	26.00	39.00																						13.00	26.00	19.50																		13.00					13.00					1		
H0564	006	0	1	01	01	H0564_006_0	8	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				4.00	8.00	12.00																						4.00	8.00	6.00																		4.00					4.00					1		
H0564	047	0	1	01	01	H0564_047_0	8	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					723.00	33																							33																			33				33			33			
H0564	047	0	1	01	01	H0564_047_0	8	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	14.00	10.50																		7.00					7.00					1		
H0564	047	0	1	01	01	H0564_047_0	8	2	Non-Preferred Generic	3	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				15.00	30.00	45.00																						15.00	30.00	22.50																		15.00					15.00					1		
H0564	047	0	1	01	01	H0564_047_0	8	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	14.00	10.50																		7.00					7.00							
H0564	047	0	1	01	01	H0564_047_0	8	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				15.00	30.00	45.00																						15.00	30.00	22.50																		15.00					15.00							
H0564	047	0	1	01	01	H0564_047_0	8	3	Preferred Brand	1	4	010001	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00					45.00			45.00				
H0564	047	0	1	01	01	H0564_047_0	8	4	Non-Preferred Brand	1	4	110000	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H0564	047	0	1	01	01	H0564_047_0	8	5	Injectable Drugs	1	4	010010	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H0564	048	0	1	01	01	H0564_048_0	8	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	14.00	10.50																		7.00					7.00					1		
H0564	048	0	1	01	01	H0564_048_0	8	2	Non-Preferred Generic	3	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				13.00	26.00	39.00																						13.00	26.00	19.50																		13.00					13.00					1		
H0564	048	0	1	01	01	H0564_048_0	8	5	Injectable Drugs	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					90.00	33	33	33																					33	33	33																	33				33			33			
H0564	048	0	1	01	01	H0564_048_0	8	4	Non-Preferred Brand	1	4	110000	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		80.00	160.00	240.00																						80.00	160.00	200.00																		80.00					80.00			80.00				
H0564	048	0	1	01	01	H0564_048_0	8	3	Preferred Brand	1	4	010001	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		36.00	72.00	108.00																						36.00	72.00	90.00																		36.00					36.00			36.00				
H0564	048	0	1	01	01	H0564_048_0	8	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					952.00	33																							33																			33				33			33			
H0564	048	0	1	01	01	H0564_048_0	8	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	14.00	10.50																		7.00					7.00							
H0564	048	0	1	01	01	H0564_048_0	8	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				13.00	26.00	39.00																						13.00	26.00	19.50																		13.00					13.00							
H0564	049	0	1	01	01	H0564_049_0	9	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	14.00	10.50																		7.00					7.00							
H0564	049	0	1	01	01	H0564_049_0	9	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				13.00	26.00	39.00																						13.00	26.00	19.50																		13.00					13.00							
H0564	049	0	1	01	01	H0564_049_0	9	3	Preferred Brand	1	4	010001	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		36.00	72.00	108.00																						36.00	72.00	90.00																		36.00					36.00			36.00				
H0564	049	0	1	01	01	H0564_049_0	9	4	Non-Preferred Brand	1	4	110000	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		80.00	160.00	240.00																						80.00	160.00	200.00																		80.00					80.00			80.00				
H0564	049	0	1	01	01	H0564_049_0	9	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	14.00	10.50																		7.00					7.00					1		
H0564	049	0	1	01	01	H0564_049_0	9	2	Non-Preferred Generic	3	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				13.00	26.00	39.00																						13.00	26.00	19.50																		13.00					13.00					1		
H0564	049	0	1	01	01	H0564_049_0	9	5	Injectable Drugs	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					90.00	33	33	33																					33	33	33																	33				33			33			
H0564	049	0	1	01	01	H0564_049_0	9	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					952.00	33																							33																			33				33			33			
H0564	050	0	1	01	01	H0564_050_0	9	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	14.00	10.50																		7.00					7.00					1		
H0564	050	0	1	01	01	H0564_050_0	9	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				13.00	26.00	39.00																						13.00	26.00	19.50																		13.00					13.00							
H0564	050	0	1	01	01	H0564_050_0	9	5	Injectable Drugs	1	4	010010	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H0564	050	0	1	01	01	H0564_050_0	9	4	Non-Preferred Brand	1	4	110000	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		80.00	160.00	240.00																						80.00	160.00	200.00																		80.00					80.00			80.00				
H0564	050	0	1	01	01	H0564_050_0	9	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					723.00	33																							33																			33				33			33			
H0564	050	0	1	01	01	H0564_050_0	9	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	14.00	10.50																		7.00					7.00							
H0564	050	0	1	01	01	H0564_050_0	9	2	Non-Preferred Generic	3	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				13.00	26.00	39.00																						13.00	26.00	19.50																		13.00					13.00					1		
H0564	050	0	1	01	01	H0564_050_0	9	3	Preferred Brand	1	4	010001	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		36.00	72.00	108.00																						36.00	72.00	90.00																		36.00					36.00			36.00				
H0564	052	0	1	01	01	H0564_052_0	9	4	Non-Preferred Brand	1	4	110000	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		80.00	160.00	240.00																						80.00	160.00	200.00																		80.00					80.00			80.00				
H0564	052	0	1	01	01	H0564_052_0	9	5	Injectable Drugs	1	4	010010	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H0564	052	0	1	01	01	H0564_052_0	9	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					723.00	33																							33																			33				33			33			
H0564	052	0	1	01	01	H0564_052_0	9	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	14.00	10.50																		7.00					7.00					1		
H0564	052	0	1	01	01	H0564_052_0	9	3	Preferred Brand	1	4	010001	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		36.00	72.00	108.00																						36.00	72.00	90.00																		36.00					36.00			36.00				
H0564	052	0	1	01	01	H0564_052_0	9	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				13.00	26.00	39.00																						13.00	26.00	19.50																		13.00					13.00							
H0564	052	0	1	01	01	H0564_052_0	9	2	Non-Preferred Generic	3	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				13.00	26.00	39.00																						13.00	26.00	19.50																		13.00					13.00					1		
H0564	052	0	1	01	01	H0564_052_0	9	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	14.00	10.50																		7.00					7.00							
H0571	001	0	1	01	01	H0571_001_0	8	1	Generic	1	4	010000	1	2	000011111101001000000110				30	60	90	30	60	90	1			90								14	31	14												10.00	20.00	20.00						10.00	20.00	30.00								20.00																			10.00				10.00							
H0571	001	0	1	01	01	H0571_001_0	8	2	Preferred Brand	1	4	000001	1	2	100011111101001000000001				30	60	90	30	60	90	1			90								14			31	14										40.00	80.00	80.00						40.00	80.00	120.00								80.00																			40.00							40.00				
H0571	001	0	1	01	01	H0571_001_0	8	3	Specialty Tier	1	4	000001	1	1	100011111101001000000001				30	60	90	30	60	90	2			90								14			31	14													258.87	20	20	20					258.87	20	20	20							20																		20						20			
H0571	002	0	2	01	01	H0571_002_0	8	1	Generic	1	4	010000	1	2	000011111101001000000110				30	60	90	30	60	90	1			90								14	31	14												10.00	20.00	20.00						10.00	20.00	30.00								20.00																			10.00				10.00							
H0571	002	0	2	01	01	H0571_002_0	8	2	Preferred Brand	1	4	000001	1	2	100011111101001000000001				30	60	90	30	60	90	1			90								14			31	14										40.00	80.00	80.00						40.00	80.00	120.00								80.00																			40.00							40.00				
H0571	002	0	2	01	01	H0571_002_0	8	3	Specialty Tier	1	4	000001	1	1	100011111101001000000001				30	60	90	30	60	90	2			90								14			31	14													258.30	20	20	20					258.30	20	20	20							20																		20						20			
H0602	017	0	1	18	06	H0602_017_0	10	1	Preferred Generic	1	4	001010	1	2	110100000010001000000101	30		90							2			90							30		31		31	14		3.00		9.00																								7.50																		3.00					3.00			3.00				
H0602	017	0	1	18	06	H0602_017_0	10	5	Specialty Tier	1	4	010010	1	1	110100000010001000000101	30		90							2			90							30		31		31	14					969.03	33		33																							33																	33				33			33			
H0602	017	0	1	18	06	H0602_017_0	10	4	Non-Preferred Brand	1	4	110000	1	2	110100000010001000000101	30		90							2			90							30		31		31	14		65.00		195.00																								162.50																		65.00					65.00			65.00				
H0602	017	0	1	18	06	H0602_017_0	10	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		45.00		135.00																								112.50																		45.00								45.00				
H0602	017	0	1	18	06	H0602_017_0	10	2	Non-Preferred Generic	1	4	000110	1	2	110100000010001000000101	30		90							2			90							30		31		31	14		12.00		36.00																								30.00																		12.00					12.00			12.00				
H0602	019	0	1	18	06	H0602_019_0	9	2	Non-Preferred Generic	1	4	000110	1	2	110100000010001000000101	30		90							2			90							30		31		31	14		9.00		27.00																								22.50																		9.00					9.00			9.00				
H0602	019	0	1	18	06	H0602_019_0	9	1	Preferred Generic	1	4	001010	1	2	110100000010001000000101	30		90							2			90							30		31		31	14		3.00		9.00																								7.50																		3.00					3.00			3.00				
H0602	019	0	1	18	06	H0602_019_0	9	2	Non-Preferred Generic	3	4	000110	1	2	110100000010001000000101	30		90							2			90							30		31		31	14		9.00		27.00																								22.50																		9.00					9.00			9.00		1		
H0602	019	0	1	18	06	H0602_019_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		40.00		120.00																								100.00																		40.00								40.00				
H0602	019	0	1	18	06	H0602_019_0	9	4	Non-Preferred Brand	1	4	110000	1	2	110100000010001000000101	30		90							2			90							30		31		31	14		60.00		180.00																								150.00																		60.00					60.00			60.00				
H0602	019	0	1	18	06	H0602_019_0	9	5	Specialty Tier	1	4	010010	1	1	110100000010001000000101	30		90							2			90							30		31		31	14					1178.08	33		33																							33																	33				33			33			
H0602	019	0	1	18	06	H0602_019_0	9	1	Preferred Generic	3	4	001010	1	2	110100000010001000000101	30		90							2			90							30		31		31	14		3.00		9.00																								7.50																		3.00					3.00			3.00		1		
H0602	020	0	1	18	06	H0602_020_0	10	1	Preferred Generic	1	4	001010	1	2	110100000010001000000101	30		90							2			90							30		31		31	14		3.00		9.00																								7.50																		3.00					3.00			3.00				
H0602	020	0	1	18	06	H0602_020_0	10	2	Non-Preferred Generic	1	4	000110	1	2	110100000010001000000101	30		90							2			90							30		31		31	14		12.00		36.00																								30.00																		12.00					12.00			12.00				
H0602	020	0	1	18	06	H0602_020_0	10	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		45.00		135.00																								112.50																		45.00								45.00				
H0602	020	0	1	18	06	H0602_020_0	10	5	Specialty Tier	1	4	010010	1	1	110100000010001000000101	30		90							2			90							30		31		31	14					948.53	33		33																							33																	33				33			33			
H0602	020	0	1	18	06	H0602_020_0	10	4	Non-Preferred Brand	1	4	110000	1	2	110100000010001000000101	30		90							2			90							30		31		31	14		65.00		195.00																								162.50																		65.00					65.00			65.00				
H0602	022	0	1	18	06	H0602_022_0	10	5	Specialty Tier	1	4	010010	1	1	110100000010001000000101	30		90							2			90							30		31		31	14					1296.96	33		33																							33																	33				33			33			
H0602	022	0	1	18	06	H0602_022_0	10	4	Non-Preferred Brand	1	4	110000	1	2	110100000010001000000101	30		90							2			90							30		31		31	14		65.00		195.00																								162.50																		65.00					65.00			65.00				
H0602	022	0	1	18	06	H0602_022_0	10	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		45.00		135.00																								112.50																		45.00								45.00				
H0602	022	0	1	18	06	H0602_022_0	10	2	Non-Preferred Generic	1	4	000110	1	2	110100000010001000000101	30		90							2			90							30		31		31	14		12.00		36.00																								30.00																		12.00					12.00			12.00				
H0602	022	0	1	18	06	H0602_022_0	10	1	Preferred Generic	1	4	001010	1	2	110100000010001000000101	30		90							2			90							30		31		31	14		3.00		9.00																								7.50																		3.00					3.00			3.00				
H0602	039	0	1	18	06	H0602_039_0	10	4	Non-Preferred Brand	1	4	110000	1	2	110100000010001000000101	30		90							2			90							30		31		31	14		90.00		270.00																								225.00																		90.00					90.00			90.00				
H0602	039	0	1	18	06	H0602_039_0	10	5	Specialty Tier	1	4	010010	1	1	110100000010001000000101	30		90							2			90							30		31		31	14					741.32	33		33																							33																	33				33			33			
H0602	039	0	1	18	06	H0602_039_0	10	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		45.00		135.00																								112.50																		45.00								45.00				
H0602	039	0	1	18	06	H0602_039_0	10	2	Non-Preferred Generic	1	4	000110	1	2	110100000010001000000101	30		90							2			90							30		31		31	14		12.00		36.00																								30.00																		12.00					12.00			12.00				
H0602	039	0	1	18	06	H0602_039_0	10	1	Preferred Generic	1	4	001010	1	2	110100000010001000000101	30		90							2			90							30		31		31	14		3.00		9.00																								7.50																		3.00					3.00			3.00				
H0602	043	0	1	18	06	H0602_043_0	11	5	Specialty Tier	1	3	010010		1	110100000010001000000101	30		90							2			90							30		31		31	14					821.25	30		30																							30																	30				30			30			
H0602	043	0	1	18	06	H0602_043_0	11	1	Preferred Generic	1	3	001010		2	110100000010001000000101	30		90							2			90							30		31		31	14		2.00		6.00																								6.00																		2.00					2.00			2.00				
H0602	043	0	1	18	06	H0602_043_0	11	2	Non-Preferred Generic	1	3	000110		2	110100000010001000000101	30		90							2			90							30		31		31	14		13.00		39.00																								39.00																		13.00					13.00			13.00				
H0602	043	0	1	18	06	H0602_043_0	11	3	Preferred Brand	1	3	000001		2	110100000010001000000001	30		90							2			90							30				31	14		40.00		120.00																								120.00																		40.00								40.00				
H0602	043	0	1	18	06	H0602_043_0	11	4	Non-Preferred Brand	1	3	110000		2	110100000010001000000101	30		90							2			90							30		31		31	14		80.00		240.00																								240.00																		80.00					80.00			80.00				
H0609	002	0	1	01	01	H0609_002_0	7	1	Preferred Generic	3	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00					1		
H0609	002	0	1	01	01	H0609_002_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					539.00	33		33																														33							33			33				33			33			
H0609	002	0	1	01	01	H0609_002_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		91.00		273.00																															263.00							273.00				91.00					91.00			91.00				
H0609	002	0	1	01	01	H0609_002_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		42.00		126.00																															116.00							126.00				42.00					42.00			42.00				
H0609	002	0	1	01	01	H0609_002_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H0609	002	0	1	01	01	H0609_002_0	7	2	Non-Preferred Generic	3	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00					1		
H0609	002	0	1	01	01	H0609_002_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H0609	007	0	1	01	01	H0609_007_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H0609	007	0	1	01	01	H0609_007_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H0609	007	0	1	01	01	H0609_007_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					506.00	33		33																														33							33			33				33			33			
H0609	007	0	1	01	01	H0609_007_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		91.00		273.00																															263.00							273.00				91.00					91.00			91.00				
H0609	007	0	1	01	01	H0609_007_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		42.00		126.00																															116.00							126.00				42.00					42.00			42.00				
H0609	012	0	1	01	01	H0609_012_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H0609	012	0	1	01	01	H0609_012_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H0609	012	0	1	01	01	H0609_012_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H0609	012	0	1	01	01	H0609_012_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H0609	012	0	1	01	01	H0609_012_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					509.00	33		33																														33							33			33				33			33			
H0609	020	0	1	01	01	H0609_020_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H0609	020	0	1	01	01	H0609_020_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H0609	020	0	1	01	01	H0609_020_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H0609	020	0	1	01	01	H0609_020_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H0609	020	0	1	01	01	H0609_020_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					530.00	33		33																														33							33			33				33			33			
H0621	006	0	1	01	01	H0621_006_0	7	1	Preferred Generic	1	2	001001		2	110100000010101000000101	30		90							1	30		90							30		31		31	14		7.00		21.00																						7.00		14.00																		7.00					7.00			7.00				
H0621	006	0	1	01	01	H0621_006_0	7	2	Preferred Brand	1	2	001001		2	110100000010101000000101	30		90							1	30		90							30		31		31	14		45.00		135.00																						45.00		90.00																		45.00					45.00			45.00				
H0621	006	0	1	01	01	H0621_006_0	7	3	Non-Preferred Brand	1	2	100100		2	110100000010101000000101	30		90							1	30		90							30		31		31	14		95.00		285.00																						95.00		190.00																		95.00					95.00			95.00				
H0621	006	0	1	01	01	H0621_006_0	7	4	Specialty Tier	1	2	010010		1	110000000010100000000101	30										30									30		31		31	14					668.00	25																							25																			25				25			25			
H0621	010	0	1	01	01	H0621_010_0	8	1	Preferred Generic	1	2	001001		2	110100000010101000000101	30		90							1	30		90							30		31		31	14		7.50		22.50																						7.50		15.00																		7.50					7.50			7.50				
H0621	010	0	1	01	01	H0621_010_0	8	2	Preferred Brand	1	2	001001		2	110100000010101000000101	30		90							1	30		90							30		31		31	14		45.00		135.00																						45.00		90.00																		45.00					45.00			45.00				
H0621	010	0	1	01	01	H0621_010_0	8	3	Non-Preferred Brand	1	2	100100		2	110100000010101000000101	30		90							1	30		90							30		31		31	14		95.00		285.00																						95.00		190.00																		95.00					95.00			95.00				
H0621	010	0	1	01	01	H0621_010_0	8	4	Specialty Tier	1	2	010010		1	110000000010100000000101	30										30									30		31		31	14					484.00	25																							25																			25				25			25			
H0623	001	0	1	04	01	H0623_001_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		84.00		252.00																													84.00		242.00					84.00		252.00				84.00					84.00			84.00		2	3	
H0623	001	0	1	04	01	H0623_001_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					936.00	33																														33							33					33				33			33	2	3	
H0623	001	0	1	04	01	H0623_001_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		42.00		126.00																													42.00		116.00					42.00		126.00				42.00					42.00			42.00		2	2	
H0623	001	0	1	04	01	H0623_001_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H0623	001	0	1	04	01	H0623_001_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00		2	3	1
H0623	001	0	1	04	01	H0623_001_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					805.00	33																														33							33					33				33			33			
H0623	001	0	1	04	01	H0623_001_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		84.00		252.00																													84.00		242.00					84.00		252.00				84.00					84.00			84.00				
H0623	001	0	1	04	01	H0623_001_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		42.00		126.00																													42.00		116.00					42.00		126.00				42.00					42.00			42.00				
H0623	001	0	1	04	01	H0623_001_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H0623	001	0	1	04	01	H0623_001_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H0623	011	0	1	04	01	H0623_011_0	7	5	Specialty Tier	3	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													775.00	25							786.00	25														25							25					25				25			25	2	3	
H0623	011	0	1	04	01	H0623_011_0	7	4	Non-Preferred Brand	3	4	110000	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													127.00	30		30					129.00	50		50												30		30					50		50			50				50			50	2	3	
H0623	011	0	1	04	01	H0623_011_0	7	3	Preferred Brand	3	4	000101	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													23.00	18		18					33.00	25		25												18		18					25		25			25				25			25	2	2	
H0623	011	0	1	04	01	H0623_011_0	7	2	Non-Preferred Generic	3	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										3.00		9.00						10.00		30.00													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	3	
H0623	011	0	1	04	01	H0623_011_0	7	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										1.00		3.00						8.00		24.00													0.00		0.00					8.00		24.00				8.00					8.00			8.00				
H0623	011	0	1	04	01	H0623_011_0	7	4	Non-Preferred Brand	1	4	110000	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													99.00	30		30					101.00	50		50												30		30					50		50			50				50			50			
H0623	011	0	1	04	01	H0623_011_0	7	3	Preferred Brand	1	4	000101	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													17.00	18		18					25.00	25		25												18		18					25		25			25				25			25			
H0623	011	0	1	04	01	H0623_011_0	7	2	Non-Preferred Generic	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										3.00		9.00						10.00		30.00													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H0623	011	0	1	04	01	H0623_011_0	7	5	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													689.00	25							700.00	25														25							25					25				25			25			
H0630	013	0	1	01	01	H0630_013_0	7	6	Vaccines	3	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00										1		
H0630	013	0	1	01	01	H0630_013_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					7.00		21.00																						7.00		14.00																		7.00					7.00							
H0630	013	0	1	01	01	H0630_013_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00							
H0630	013	0	1	01	01	H0630_013_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		45.00		135.00																						45.00		90.00																		45.00								45.00				
H0630	013	0	1	01	01	H0630_013_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		75.00		225.00																						75.00		150.00																		75.00								75.00				
H0630	013	0	1	01	01	H0630_013_0	7	5	Specialty Tier	1	4	100001	1	1	110100000010101000000001	30		90							2	30		90							30				31	14					580.00	25		25																					25		25																	25							25			
H0630	013	0	1	01	01	H0630_013_0	7	6	Vaccines	1	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00												
H0630	013	0	1	01	01	H0630_013_0	7	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					7.00		21.00																						7.00		14.00																		7.00					7.00					1		
H0630	013	0	1	01	01	H0630_013_0	7	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00					1		
H0630	015	0	1	01	01	H0630_015_0	7	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00					1		
H0630	015	0	1	01	01	H0630_015_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00							
H0630	015	0	1	01	01	H0630_015_0	7	6	Vaccines	1	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00												
H0630	015	0	1	01	01	H0630_015_0	7	5	Specialty Tier	1	4	100001	1	1	110100000010101000000001	30		90							2	30		90							30				31	14					547.00	25		25																					25		25																	25							25			
H0630	015	0	1	01	01	H0630_015_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		75.00		225.00																						75.00		150.00																		75.00								75.00				
H0630	015	0	1	01	01	H0630_015_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		45.00		135.00																						45.00		90.00																		45.00								45.00				
H0630	015	0	1	01	01	H0630_015_0	7	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					6.00		18.00																						6.00		12.00																		6.00					6.00					1		
H0630	015	0	1	01	01	H0630_015_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					6.00		18.00																						6.00		12.00																		6.00					6.00							
H0630	015	0	1	01	01	H0630_015_0	7	6	Vaccines	3	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00										1		
H0630	016	0	1	01	01	H0630_016_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		40.00		120.00																						40.00		80.00																		40.00								40.00				
H0630	016	0	1	01	01	H0630_016_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		75.00		225.00																						75.00		150.00																		75.00								75.00				
H0630	016	0	1	01	01	H0630_016_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					4.00		12.00																						4.00		8.00																		4.00					4.00							
H0630	016	0	1	01	01	H0630_016_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00							
H0630	016	0	1	01	01	H0630_016_0	6	6	Vaccines	3	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00										1		
H0630	016	0	1	01	01	H0630_016_0	6	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00					1		
H0630	016	0	1	01	01	H0630_016_0	6	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					4.00		12.00																						4.00		8.00																		4.00					4.00					1		
H0630	016	0	1	01	01	H0630_016_0	6	6	Vaccines	1	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00												
H0630	016	0	1	01	01	H0630_016_0	6	5	Specialty Tier	1	4	100001	1	1	110100000010101000000001	30		90							2	30		90							30				31	14					583.00	25		25																					25		25																	25							25			
H0630	017	0	1	01	01	H0630_017_0	7	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					7.00		21.00																						7.00		14.00																		7.00					7.00					1		
H0630	017	0	1	01	01	H0630_017_0	7	5	Specialty Tier	1	4	100001	1	1	110100000010101000000001	30		90							2	30		90							30				31	14					398.00	25		25																					25		25																	25							25			
H0630	017	0	1	01	01	H0630_017_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		75.00		225.00																						75.00		150.00																		75.00								75.00				
H0630	017	0	1	01	01	H0630_017_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		45.00		135.00																						45.00		90.00																		45.00								45.00				
H0630	017	0	1	01	01	H0630_017_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00							
H0630	017	0	1	01	01	H0630_017_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					7.00		21.00																						7.00		14.00																		7.00					7.00							
H0630	017	0	1	01	01	H0630_017_0	7	6	Vaccines	1	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00												
H0630	017	0	1	01	01	H0630_017_0	7	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00					1		
H0630	017	0	1	01	01	H0630_017_0	7	6	Vaccines	3	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00										1		
H0630	018	0	1	01	01	H0630_018_0	6	6	Vaccines	3	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00										1		
H0630	018	0	1	01	01	H0630_018_0	6	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					7.00		21.00																						7.00		14.00																		7.00					7.00					1		
H0630	018	0	1	01	01	H0630_018_0	6	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00					1		
H0630	018	0	1	01	01	H0630_018_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					7.00		21.00																						7.00		14.00																		7.00					7.00							
H0630	018	0	1	01	01	H0630_018_0	6	6	Vaccines	1	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00												
H0630	018	0	1	01	01	H0630_018_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		45.00		135.00																						45.00		90.00																		45.00								45.00				
H0630	018	0	1	01	01	H0630_018_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		75.00		225.00																						75.00		150.00																		75.00								75.00				
H0630	018	0	1	01	01	H0630_018_0	6	5	Specialty Tier	1	4	100001	1	1	110100000010101000000001	30		90							2	30		90							30				31	14					511.00	25		25																					25		25																	25							25			
H0630	018	0	1	01	01	H0630_018_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00							
H0630	019	0	1	02	01	H0630_019_0	8	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					6.00		18.00																						6.00		12.00																		6.00					6.00					1		
H0630	019	0	1	02	01	H0630_019_0	8	6	Vaccines	1	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00												
H0630	019	0	1	02	01	H0630_019_0	8	5	Specialty Tier	1	4	100001	1	1	110100000010101000000001	30		90							2	30		90							30				31	14					757.00	25		25																					25		25																	25							25			
H0630	019	0	1	02	01	H0630_019_0	8	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		75.00		225.00																						75.00		150.00																		75.00								75.00				
H0630	019	0	1	02	01	H0630_019_0	8	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		45.00		135.00																						45.00		90.00																		45.00								45.00				
H0630	019	0	1	02	01	H0630_019_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					6.00		18.00																						6.00		12.00																		6.00					6.00							
H0630	019	0	1	02	01	H0630_019_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00							
H0630	019	0	1	02	01	H0630_019_0	8	6	Vaccines	3	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00										1		
H0630	019	0	1	02	01	H0630_019_0	8	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00					1		
H0630	020	0	1	01	01	H0630_020_0	7	6	Vaccines	3	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00										1		
H0630	020	0	1	01	01	H0630_020_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00							
H0630	020	0	1	01	01	H0630_020_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					7.00		21.00																						7.00		14.00																		7.00					7.00							
H0630	020	0	1	01	01	H0630_020_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		45.00		135.00																						45.00		90.00																		45.00								45.00				
H0630	020	0	1	01	01	H0630_020_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		75.00		225.00																						75.00		150.00																		75.00								75.00				
H0630	020	0	1	01	01	H0630_020_0	7	5	Specialty Tier	1	4	100001	1	1	110100000010101000000001	30		90							2	30		90							30				31	14					564.00	25		25																					25		25																	25							25			
H0630	020	0	1	01	01	H0630_020_0	7	6	Vaccines	1	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00												
H0630	020	0	1	01	01	H0630_020_0	7	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					7.00		21.00																						7.00		14.00																		7.00					7.00					1		
H0630	020	0	1	01	01	H0630_020_0	7	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00					1		
H0630	021	0	1	01	01	H0630_021_0	7	6	Vaccines	3	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00										1		
H0630	021	0	1	01	01	H0630_021_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					6.00		18.00																						6.00		12.00																		6.00					6.00							
H0630	021	0	1	01	01	H0630_021_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00							
H0630	021	0	1	01	01	H0630_021_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		45.00		135.00																						45.00		90.00																		45.00								45.00				
H0630	021	0	1	01	01	H0630_021_0	7	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00					1		
H0630	021	0	1	01	01	H0630_021_0	7	5	Specialty Tier	1	4	100001	1	1	110100000010101000000001	30		90							2	30		90							30				31	14					554.00	25		25																					25		25																	25							25			
H0630	021	0	1	01	01	H0630_021_0	7	6	Vaccines	1	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00												
H0630	021	0	1	01	01	H0630_021_0	7	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					6.00		18.00																						6.00		12.00																		6.00					6.00					1		
H0630	021	0	1	01	01	H0630_021_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		75.00		225.00																						75.00		150.00																		75.00								75.00				
H0712	001	0	1	02	01	H0712_001_0	8	1	Generic	1	4	010010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		5.00	10.00	15.00																													5.00	10.00	0.00							15.00				5.00					5.00			5.00				
H0712	001	0	1	02	01	H0712_001_0	8	2	Preferred Brand	1	4	000001	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		39.00	78.00	117.00																													39.00	78.00	78.00							117.00				39.00								39.00				
H0712	001	0	1	02	01	H0712_001_0	8	3	Non-Preferred Brand	1	4	100000	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		79.00	158.00	237.00																													79.00	158.00	158.00							237.00				79.00								79.00				
H0712	001	0	1	02	01	H0712_001_0	8	4	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
H0712	005	0	1	01	01	H0712_005_0	6	1	Preferred Generic	1	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
H0712	005	0	1	01	01	H0712_005_0	6	2	Preferred Brand	1	4	010001	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		45.00	90.00	135.00																													45.00	90.00	90.00							135.00				45.00					45.00			45.00				
H0712	005	0	1	01	01	H0712_005_0	6	3	Non-Preferred Brand	1	4	110000	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		94.00	188.00	282.00																													94.00	188.00	188.00							282.00				94.00					94.00			94.00				
H0712	005	0	1	01	01	H0712_005_0	6	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	31													31			31			31		31		31	14					707.00	25																														25							25					25				25			25			
H0712	019	0	1	01	01	H0712_019_0	8	4	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
H0712	019	0	1	01	01	H0712_019_0	8	3	Non-Preferred Brand	1	4	100000	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		89.00	178.00	267.00																													89.00	178.00	178.00							267.00				89.00								89.00				
H0712	019	0	1	01	01	H0712_019_0	8	1	Generic	1	4	010010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		5.00	10.00	15.00																													5.00	10.00	0.00							15.00				5.00					5.00			5.00				
H0712	019	0	1	01	01	H0712_019_0	8	2	Preferred Brand	1	4	000001	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		45.00	90.00	135.00																													45.00	90.00	90.00							135.00				45.00								45.00				
H0752	002	0	1	02	01	H0752_002_0	7	3	Preferred Brand	1	3	010001		2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H0752	002	0	1	02	01	H0752_002_0	7	2	Non-Preferred Generic	1	3	000100		2	010100000010000001001100	31		90							1						90			90	31		31					8.00		24.00																															16.00							24.00				8.00					8.00							
H0752	002	0	1	02	01	H0752_002_0	7	1	Preferred Generic	1	3	001000		2	010100000010000001001100	31		90							1						90			90	31		31					5.00		15.00																															10.00							15.00				5.00					5.00							
H0752	002	0	1	02	01	H0752_002_0	7	4	Non-Preferred Brand	1	3	100100		2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H0752	002	0	1	02	01	H0752_002_0	7	5	Specialty Tier	1	3	010010		1	110100000010000001001101	31		90							1						90			90	31		31		31	14					432.00	33		33																														33							33			33				33			33			
H0755	030	0	1	01	01	H0755_030_0	7	2	Non-Preferred Generic	3	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00					1		
H0755	030	0	1	01	01	H0755_030_0	7	1	Preferred Generic	3	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00					1		
H0755	030	0	1	01	01	H0755_030_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					537.00	33		33																														33							33			33				33			33			
H0755	030	0	1	01	01	H0755_030_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		91.00		273.00																															263.00							273.00				91.00					91.00			91.00				
H0755	030	0	1	01	01	H0755_030_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		43.00		129.00																															119.00							129.00				43.00					43.00			43.00				
H0755	030	0	1	01	01	H0755_030_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H0755	030	0	1	01	01	H0755_030_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H0755	031	0	1	01	01	H0755_031_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					560.00	33		33																														33							33			33				33			33			
H0755	031	0	1	01	01	H0755_031_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H0755	031	0	1	01	01	H0755_031_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					7.00		21.00																															14.00							21.00				7.00					7.00							
H0755	031	0	1	01	01	H0755_031_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					4.00		12.00																															8.00							12.00				4.00					4.00							
H0755	031	0	1	01	01	H0755_031_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H0838	022	0	1	01	01	H0838_022_0	7	2	Brand	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		40.00		120.00																								80.00																		40.00								40.00				
H0838	022	0	1	01	01	H0838_022_0	7	1	Generic	1	4	010000	1	2	010100000010001000000110	30		90							1			90							30		31	14				5.00		15.00																								10.00																		5.00					5.00							
H0838	022	0	1	01	01	H0838_022_0	7	1	Generic	3	4	010000	1	2	010100000010001000000110	30		90							1			90							30		31	14				5.00		15.00																								10.00																		5.00					5.00					1		
H0879	001	0	1	04	01	H0879_001_0	3	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	31		90							1			90							31				31	14		82.00		205.00																								205.00																		82.00								82.00				
H0879	001	0	1	04	01	H0879_001_0	3	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	31		90							1			90							31				31	14		41.00		102.50																								102.50																		41.00								41.00				
H0879	001	0	1	04	01	H0879_001_0	3	5	Specialty Tier	1	4	010010	1	1	110100000010001000000111	31		90							1			90							31		31	14	31	14					510.00	33		33																							33																	33				33			33			
H0879	001	0	1	04	01	H0879_001_0	3	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				0.00		0.00																								0.00																		0.00					0.00							
H0879	001	0	1	04	01	H0879_001_0	3	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	31		90							1			90							31		31	14				8.00		20.00																								20.00																		8.00					8.00							
H0879	002	0	1	04	01	H0879_002_0	3	5	Specialty Tier	1	4	010010	1	1	110100000010001000000111	31		90							1			90							31		31	14	31	14					490.00	33		33																							33																	33				33			33			
H0879	002	0	1	04	01	H0879_002_0	3	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	31		90							1			90							31				31	14		95.00		237.50																								237.50																		95.00								95.00				
H0879	002	0	1	04	01	H0879_002_0	3	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	31		90							1			90							31				31	14		45.00		112.50																								112.50																		45.00								45.00				
H0879	002	0	1	04	01	H0879_002_0	3	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				5.00		12.50																								12.50																		5.00					5.00							
H0879	002	0	1	04	01	H0879_002_0	3	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	31		90							1			90							31		31	14				15.00		37.50																								37.50																		15.00					15.00							
H0901	004	0	1	01	01	H0901_004_0	6	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					7.00	14.00	21.00																													7.00	14.00	14.00					7.00	14.00	21.00					7.00				7.00							
H0901	004	0	1	01	01	H0901_004_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H0901	004	0	1	01	01	H0901_004_0	6	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H0901	004	0	1	01	01	H0901_004_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H0901	004	0	1	01	01	H0901_004_0	6	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					212.98	33	33	33																												33	33	33					33	33	33				33			33			33			
H0908	001	0	1	01	01	H0908_001_0	9	4	Injectable Drugs	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	7		95.00		95.00																								95.00																		95.00								95.00				
H0908	001	0	1	01	01	H0908_001_0	9	1	Generic	1	4	010000	1	2	010100000010001000000100	30		90							2			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H0908	001	0	1	01	01	H0908_001_0	9	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	7		45.00		45.00																								45.00																		45.00								45.00				
H0908	001	0	1	01	01	H0908_001_0	9	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							2			90							30				31	7		95.00		95.00																								95.00																		95.00								95.00				
H0913	002	0	1	01	01	H0913_002_0	7	4	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
H0913	002	0	1	01	01	H0913_002_0	7	3	Non-Preferred Brand	1	4	100000	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		70.00	140.00	210.00																													70.00	140.00	140.00							210.00				70.00								70.00				
H0913	002	0	1	01	01	H0913_002_0	7	1	Generic	1	4	010010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		4.00	8.00	12.00																													4.00	8.00	0.00							12.00				4.00					4.00			4.00				
H0913	002	0	1	01	01	H0913_002_0	7	2	Preferred Brand	1	4	000001	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		35.00	70.00	105.00																													35.00	70.00	70.00							105.00				35.00								35.00				
H0979	022	0	1	09	04	H0979_022_0	8	1	Preferred Generic	1	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		4.00		12.00																						4.00		10.00																		4.00					4.00			4.00				
H0979	022	0	1	09	04	H0979_022_0	8	2	Preferred Brand	1	4	000101	1	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		44.00		132.00																						44.00		110.00																		44.00					44.00			44.00				
H0979	022	0	1	09	04	H0979_022_0	8	3	Non-Preferred Brand	1	4	100100	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		78.00		234.00																						78.00		195.00																		78.00					78.00			78.00				
H0979	022	0	1	09	04	H0979_022_0	8	4	Specialty Tier	1	4	100100	1	1	110100000010101000000111	30		90							1	30		90							30		31	14	31	14					707.88	33		33																					33		33																	33				33			33			
H1013	011	0	1	01	01	H1013_011_0	13	3	Non-Preferred Brand	1	4	100100	1	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										20.00		60.00						25.00		75.00						20.00		60.00																		25.00					20.00			20.00				
H1013	011	0	1	01	01	H1013_011_0	13	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													594.41	33							594.41	33																										33				33			33			
H1013	011	0	1	01	01	H1013_011_0	13	1	Preferred Generic	3	4	001010	3	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										0.00		0.00						0.00		0.00						0.00		0.00																		0.00					0.00			0.00		1		
H1013	011	0	1	01	01	H1013_011_0	13	1	Preferred Generic	1	4	001010	3	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										0.00		0.00						0.00		0.00						0.00		0.00																		0.00					0.00			0.00				
H1013	011	0	1	01	01	H1013_011_0	13	2	Preferred Brand	1	4	000001	1	2	100010110110101000000001				30		90	30		90	2	30		90							30				31	14										0.00		0.00						0.00		0.00						0.00		0.00																		0.00								0.00				
H1013	021	0	1	01	01	H1013_021_0	5	1	Preferred Generic	3	4	001010	3	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		5.00		10.00																						5.00		10.00																		5.00					5.00			5.00		1		
H1013	021	0	1	01	01	H1013_021_0	5	4	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					513.26	33																																										33				33			33			
H1013	021	0	1	01	01	H1013_021_0	5	3	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		75.00		225.00																						75.00		225.00																		75.00					75.00			75.00				
H1013	021	0	1	01	01	H1013_021_0	5	1	Preferred Generic	1	4	001010	3	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00				
H1013	021	0	1	01	01	H1013_021_0	5	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		30.00		60.00																						30.00		60.00																		30.00								30.00				
H1013	024	0	1	01	01	H1013_024_0	6	1	Preferred Generic	3	4	001010	3	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00		1		
H1013	024	0	1	01	01	H1013_024_0	6	4	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					493.15	33																																										33				33			33			
H1013	024	0	1	01	01	H1013_024_0	6	3	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		76.00		228.00																						76.00		228.00																		76.00					76.00			76.00				
H1013	024	0	1	01	01	H1013_024_0	6	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		45.00		90.00																						45.00		90.00																		45.00								45.00				
H1013	024	0	1	01	01	H1013_024_0	6	1	Preferred Generic	1	4	001010	3	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00				
H1016	001	0	1	01	01	H1016_001_0	6	1	Preferred Generic	1	4	001000	3	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H1016	001	0	1	01	01	H1016_001_0	6	2	Non-Preferred Generic	1	4	000100	3	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H1016	001	0	1	01	01	H1016_001_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		25.00		75.00																								75.00																		25.00								25.00				
H1016	001	0	1	01	01	H1016_001_0	6	2	Non-Preferred Generic	3	4	000100	3	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H1016	001	0	1	01	01	H1016_001_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					696.39	33																																										33				33			33			
H1016	001	0	1	01	01	H1016_001_0	6	1	Preferred Generic	3	4	001000	3	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H1016	001	0	1	01	01	H1016_001_0	6	4	Non-Preferred Brand	1	4	100000	3	2	110100000010001000000001	30		90							1			90							30				31	14		50.00		150.00																								150.00																		50.00								50.00				
H1019	001	0	1	01	01	H1019_001_0	3	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1019	001	0	1	01	01	H1019_001_0	3	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													7.00		11.00					7.00		21.00				7.00					7.00			7.00				
H1019	001	0	1	01	01	H1019_001_0	3	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		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	3	1	Preferred Generic	1	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		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	3	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					775.00	33																														33							33					33				33			33	2	1	
H1019	001	0	1	01	01	H1019_001_0	3	1	Preferred Generic	3	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1019	001	0	1	01	01	H1019_001_0	3	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1019	001	0	1	01	01	H1019_001_0	3	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													7.00		11.00					7.00		21.00				7.00					7.00			7.00		2	3	
H1019	001	0	1	01	01	H1019_001_0	3	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	3	
H1019	001	0	1	01	01	H1019_001_0	3	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					556.00	33																														33							33					33				33			33			
H1019	004	0	1	01	01	H1019_004_0	3	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1019	004	0	1	01	01	H1019_004_0	3	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		20.00		60.00																													20.00		50.00					20.00		60.00				20.00					20.00			20.00				
H1019	004	0	1	01	01	H1019_004_0	3	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1019	004	0	1	01	01	H1019_004_0	3	1	Preferred Generic	1	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1019	004	0	1	01	01	H1019_004_0	3	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					539.00	33																														33							33					33				33			33			
H1019	004	0	1	01	01	H1019_004_0	3	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					642.00	33																														33							33					33				33			33	2	1	
H1019	004	0	1	01	01	H1019_004_0	3	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	3	
H1019	004	0	1	01	01	H1019_004_0	3	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		20.00		60.00																													20.00		50.00					20.00		60.00				20.00					20.00			20.00		2	3	
H1019	004	0	1	01	01	H1019_004_0	3	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	
H1019	004	0	1	01	01	H1019_004_0	3	1	Preferred Generic	3	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	3
H1019	006	0	1	01	01	H1019_006_0	3	1	Preferred Generic	1	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		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	3	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		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	3	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		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	3	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		25.00		75.00																													25.00		65.00					25.00		75.00				25.00					25.00			25.00				
H1019	006	0	1	01	01	H1019_006_0	3	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					663.00	33																														33							33					33				33			33	2	1	
H1019	006	0	1	01	01	H1019_006_0	3	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	
H1019	006	0	1	01	01	H1019_006_0	3	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1019	006	0	1	01	01	H1019_006_0	3	1	Preferred Generic	3	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1019	006	0	1	01	01	H1019_006_0	3	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					391.00	33																														33							33					33				33			33			
H1019	006	0	1	01	01	H1019_006_0	3	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		25.00		75.00																													25.00		65.00					25.00		75.00				25.00					25.00			25.00		2	3	
H1019	010	0	1	01	01	H1019_010_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		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	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		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	4	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					685.00	33																														33							33					33				33			33	2	1	
H1019	010	0	1	01	01	H1019_010_0	4	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H1019	010	0	1	01	01	H1019_010_0	4	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		35.00		105.00																													35.00		95.00					35.00		105.00				35.00					35.00			35.00		2	3	
H1019	010	0	1	01	01	H1019_010_0	4	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1019	010	0	1	01	01	H1019_010_0	4	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1019	010	0	1	01	01	H1019_010_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					653.00	33																														33							33					33				33			33			
H1019	010	0	1	01	01	H1019_010_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H1019	010	0	1	01	01	H1019_010_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		35.00		105.00																													35.00		95.00					35.00		105.00				35.00					35.00			35.00				
H1019	014	0	1	01	01	H1019_014_0	4	1	Preferred Generic	1	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		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	4	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H1019	014	0	1	01	01	H1019_014_0	4	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		25.00		75.00																													25.00		65.00					25.00		75.00				25.00					25.00			25.00		2	2	
H1019	014	0	1	01	01	H1019_014_0	4	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H1019	014	0	1	01	01	H1019_014_0	4	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					859.00	33																														33							33					33				33			33	2	1	
H1019	014	0	1	01	01	H1019_014_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					719.00	33																														33							33					33				33			33			
H1019	014	0	1	01	01	H1019_014_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H1019	014	0	1	01	01	H1019_014_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		25.00		75.00																													25.00		65.00					25.00		75.00				25.00					25.00			25.00				
H1019	014	0	1	01	01	H1019_014_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H1019	014	0	1	01	01	H1019_014_0	4	1	Preferred Generic	3	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	3
H1019	023	0	1	01	01	H1019_023_0	5	1	Preferred Generic	1	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		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	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		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	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1019	023	0	1	01	01	H1019_023_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1019	023	0	1	01	01	H1019_023_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					446.00	25																														25							25					25				25			25			
H1019	024	0	1	01	01	H1019_024_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					311.00	25																														25							25					25				25			25			
H1019	024	0	1	01	01	H1019_024_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1019	024	0	1	01	01	H1019_024_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1019	024	0	1	01	01	H1019_024_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		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	1	Preferred Generic	1	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		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	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1019	025	0	1	01	01	H1019_025_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					443.00	25																														25							25					25				25			25			
H1019	025	0	1	01	01	H1019_025_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1019	025	0	1	01	01	H1019_025_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		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	4	1	Preferred Generic	1	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		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	5	1	Preferred Generic	1	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		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	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		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	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1019	026	0	1	01	01	H1019_026_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1019	026	0	1	01	01	H1019_026_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					578.00	25																														25							25					25				25			25			
H1019	027	0	1	01	01	H1019_027_0	3	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1019	027	0	1	01	01	H1019_027_0	3	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1019	027	0	1	01	01	H1019_027_0	3	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H1019	027	0	1	01	01	H1019_027_0	3	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H1019	027	0	1	01	01	H1019_027_0	3	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					686.00	33																														33							33					33				33			33			
H1019	027	0	1	01	01	H1019_027_0	3	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	1
H1019	027	0	1	01	01	H1019_027_0	3	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	2	
H1019	027	0	1	01	01	H1019_027_0	3	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H1019	027	0	1	01	01	H1019_027_0	3	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H1019	027	0	1	01	01	H1019_027_0	3	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					780.00	33																														33							33					33				33			33	2	3	
H1019	028	0	1	01	01	H1019_028_0	5	1	Preferred Generic	1	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1019	028	0	1	01	01	H1019_028_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1019	028	0	1	01	01	H1019_028_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					511.00	25																														25							25					25				25			25			
H1019	028	0	1	01	01	H1019_028_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1019	028	0	1	01	01	H1019_028_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1019	032	0	1	01	01	H1019_032_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1019	032	0	1	01	01	H1019_032_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													10.00		20.00					10.00		30.00				10.00					10.00			10.00		2	3	
H1019	032	0	1	01	01	H1019_032_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	3	
H1019	032	0	1	01	01	H1019_032_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					849.00	33																														33							33					33				33			33	2	1	
H1019	032	0	1	01	01	H1019_032_0	5	1	Preferred Generic	3	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1019	032	0	1	01	01	H1019_032_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		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	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													10.00		20.00					10.00		30.00				10.00					10.00			10.00				
H1019	032	0	1	01	01	H1019_032_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1019	032	0	1	01	01	H1019_032_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					725.00	33																														33							33					33				33			33			
H1019	032	0	1	01	01	H1019_032_0	5	1	Preferred Generic	1	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1019	043	0	1	01	01	H1019_043_0	3	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1019	043	0	1	01	01	H1019_043_0	3	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1019	043	0	1	01	01	H1019_043_0	3	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00				
H1019	043	0	1	01	01	H1019_043_0	3	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					569.00	33																														33							33					33				33			33			
H1019	043	0	1	01	01	H1019_043_0	3	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	1
H1019	043	0	1	01	01	H1019_043_0	3	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					636.00	33																														33							33					33				33			33	2	3	
H1019	043	0	1	01	01	H1019_043_0	3	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00		2	3	
H1019	043	0	1	01	01	H1019_043_0	3	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H1019	043	0	1	01	01	H1019_043_0	3	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00		2	2	
H1019	043	0	1	01	01	H1019_043_0	3	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H1019	045	0	1	01	01	H1019_045_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					500.00	25																														25							25					25				25			25			
H1019	045	0	1	01	01	H1019_045_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1019	045	0	1	01	01	H1019_045_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1019	045	0	1	01	01	H1019_045_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		42.00		126.00																													42.00		116.00					42.00		126.00				42.00					42.00			42.00				
H1019	045	0	1	01	01	H1019_045_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1019	046	0	1	01	01	H1019_046_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					496.00	25																														25							25					25				25			25			
H1019	046	0	1	01	01	H1019_046_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1019	046	0	1	01	01	H1019_046_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1019	046	0	1	01	01	H1019_046_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		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	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		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	4	1	Preferred Generic	1	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		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	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1019	047	0	1	01	01	H1019_047_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1019	047	0	1	01	01	H1019_047_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		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	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					321.00	25																														25							25					25				25			25			
H1019	048	0	1	01	01	H1019_048_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1019	048	0	1	01	01	H1019_048_0	5	1	Preferred Generic	1	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		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	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		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	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1019	048	0	1	01	01	H1019_048_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					366.00	25																														25							25					25				25			25			
H1019	049	0	1	01	01	H1019_049_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		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	4	1	Preferred Generic	1	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		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	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1019	049	0	1	01	01	H1019_049_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1019	049	0	1	01	01	H1019_049_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					437.00	25																														25							25					25				25			25			
H1019	050	0	1	01	01	H1019_050_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1019	050	0	1	01	01	H1019_050_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1019	050	0	1	01	01	H1019_050_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					395.00	25																														25							25					25				25			25			
H1019	050	0	1	01	01	H1019_050_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		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	4	1	Preferred Generic	1	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1019	054	0	1	01	01	H1019_054_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	
H1019	054	0	1	01	01	H1019_054_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		55.00		165.00																													55.00		155.00					55.00		165.00				55.00					55.00			55.00		2	3	
H1019	054	0	1	01	01	H1019_054_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					817.00	33																														33							33					33				33			33	2	1	
H1019	054	0	1	01	01	H1019_054_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					753.00	33																														33							33					33				33			33			
H1019	054	0	1	01	01	H1019_054_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1019	054	0	1	01	01	H1019_054_0	5	1	Preferred Generic	3	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1019	054	0	1	01	01	H1019_054_0	5	1	Preferred Generic	1	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1019	054	0	1	01	01	H1019_054_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1019	054	0	1	01	01	H1019_054_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		55.00		165.00																													55.00		155.00					55.00		165.00				55.00					55.00			55.00				
H1019	054	0	1	01	01	H1019_054_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1019	056	0	1	01	01	H1019_056_0	4	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	1
H1019	056	0	1	01	01	H1019_056_0	4	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	
H1019	056	0	1	01	01	H1019_056_0	4	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		24.00		72.00																													24.00		62.00					24.00		72.00				24.00					24.00			24.00		2	3	
H1019	056	0	1	01	01	H1019_056_0	4	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	3	
H1019	056	0	1	01	01	H1019_056_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					733.00	33																														33							33					33				33			33			
H1019	056	0	1	01	01	H1019_056_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H1019	056	0	1	01	01	H1019_056_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		24.00		72.00																													24.00		62.00					24.00		72.00				24.00					24.00			24.00				
H1019	056	0	1	01	01	H1019_056_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1019	056	0	1	01	01	H1019_056_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1019	056	0	1	01	01	H1019_056_0	4	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					850.00	33																														33							33					33				33			33	2	1	
H1019	057	0	1	01	01	H1019_057_0	3	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					481.00	33																														33							33					33				33			33	2	1	
H1019	057	0	1	01	01	H1019_057_0	3	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H1019	057	0	1	01	01	H1019_057_0	3	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		20.00		60.00																													20.00		50.00					20.00		60.00				20.00					20.00			20.00		2	2	
H1019	057	0	1	01	01	H1019_057_0	3	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1019	057	0	1	01	01	H1019_057_0	3	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1019	057	0	1	01	01	H1019_057_0	3	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					400.00	33																														33							33					33				33			33			
H1019	057	0	1	01	01	H1019_057_0	3	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H1019	057	0	1	01	01	H1019_057_0	3	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1019	057	0	1	01	01	H1019_057_0	3	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1019	057	0	1	01	01	H1019_057_0	3	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		20.00		60.00																													20.00		50.00					20.00		60.00				20.00					20.00			20.00				
H1019	059	0	1	01	01	H1019_059_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		55.00		165.00																													55.00		155.00					55.00		165.00				55.00					55.00			55.00		2	3	
H1019	059	0	1	01	01	H1019_059_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	
H1019	059	0	1	01	01	H1019_059_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1019	059	0	1	01	01	H1019_059_0	5	1	Preferred Generic	3	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1019	059	0	1	01	01	H1019_059_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					747.00	33																														33							33					33				33			33	2	1	
H1019	059	0	1	01	01	H1019_059_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		55.00		165.00																													55.00		155.00					55.00		165.00				55.00					55.00			55.00				
H1019	059	0	1	01	01	H1019_059_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1019	059	0	1	01	01	H1019_059_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1019	059	0	1	01	01	H1019_059_0	5	1	Preferred Generic	1	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1019	059	0	1	01	01	H1019_059_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					737.00	33																														33							33					33				33			33			
H1019	060	0	1	01	01	H1019_060_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1019	060	0	1	01	01	H1019_060_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1019	060	0	1	01	01	H1019_060_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		25.00		75.00																													25.00		65.00					25.00		75.00				25.00					25.00			25.00				
H1019	060	0	1	01	01	H1019_060_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		55.00		165.00																													55.00		155.00					55.00		165.00				55.00					55.00			55.00				
H1019	060	0	1	01	01	H1019_060_0	4	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					758.00	33																														33							33					33				33			33	2	1	
H1019	060	0	1	01	01	H1019_060_0	4	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	1
H1019	060	0	1	01	01	H1019_060_0	4	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	2	
H1019	060	0	1	01	01	H1019_060_0	4	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		25.00		75.00																													25.00		65.00					25.00		75.00				25.00					25.00			25.00		2	2	
H1019	060	0	1	01	01	H1019_060_0	4	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		55.00		165.00																													55.00		155.00					55.00		165.00				55.00					55.00			55.00		2	3	
H1019	060	0	1	01	01	H1019_060_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					656.00	33																														33							33					33				33			33			
H1019	061	0	1	01	01	H1019_061_0	5	1	Preferred Generic	1	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1019	061	0	1	01	01	H1019_061_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1019	061	0	1	01	01	H1019_061_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1019	061	0	1	01	01	H1019_061_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1019	061	0	1	01	01	H1019_061_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					490.00	25																														25							25					25				25			25			
H1019	062	0	1	01	01	H1019_062_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1019	062	0	1	01	01	H1019_062_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1019	062	0	1	01	01	H1019_062_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													10.00		20.00					10.00		30.00				10.00					10.00			10.00				
H1019	062	0	1	01	01	H1019_062_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1019	062	0	1	01	01	H1019_062_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1019	062	0	1	01	01	H1019_062_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1019	062	0	1	01	01	H1019_062_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					822.00	33																														33							33					33				33			33	2	1	
H1019	062	0	1	01	01	H1019_062_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	3	
H1019	062	0	1	01	01	H1019_062_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													10.00		20.00					10.00		30.00				10.00					10.00			10.00		2	3	
H1019	062	0	1	01	01	H1019_062_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					687.00	33																														33							33					33				33			33			
H1019	063	0	1	01	01	H1019_063_0	8	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1103.00	33																														33							33					33				33			33	2	1	
H1019	063	0	1	01	01	H1019_063_0	8	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		25.00		75.00																													25.00		65.00					25.00		75.00				25.00					25.00			25.00		2	3	
H1019	063	0	1	01	01	H1019_063_0	8	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	
H1019	063	0	1	01	01	H1019_063_0	8	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1019	063	0	1	01	01	H1019_063_0	8	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		25.00		75.00																													25.00		65.00					25.00		75.00				25.00					25.00			25.00				
H1019	063	0	1	01	01	H1019_063_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					597.00	33																														33							33					33				33			33			
H1019	063	0	1	01	01	H1019_063_0	8	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1019	063	0	1	01	01	H1019_063_0	8	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1019	063	0	1	01	01	H1019_063_0	8	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1019	063	0	1	01	01	H1019_063_0	8	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1019	064	0	1	01	01	H1019_064_0	4	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		35.00		105.00																													35.00		95.00					35.00		105.00				35.00					35.00			35.00		2	3	
H1019	064	0	1	01	01	H1019_064_0	4	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H1019	064	0	1	01	01	H1019_064_0	4	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					837.00	33																														33							33					33				33			33	2	1	
H1019	064	0	1	01	01	H1019_064_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1019	064	0	1	01	01	H1019_064_0	4	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1019	064	0	1	01	01	H1019_064_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		35.00		105.00																													35.00		95.00					35.00		105.00				35.00					35.00			35.00				
H1019	064	0	1	01	01	H1019_064_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H1019	064	0	1	01	01	H1019_064_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					700.00	33																														33							33					33				33			33			
H1019	064	0	1	01	01	H1019_064_0	4	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1019	064	0	1	01	01	H1019_064_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1019	065	0	1	01	01	H1019_065_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H1019	065	0	1	01	01	H1019_065_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1019	065	0	1	01	01	H1019_065_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1019	065	0	1	01	01	H1019_065_0	4	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					814.00	33																														33							33					33				33			33	2	3	
H1019	065	0	1	01	01	H1019_065_0	4	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H1019	065	0	1	01	01	H1019_065_0	4	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H1019	065	0	1	01	01	H1019_065_0	4	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H1019	065	0	1	01	01	H1019_065_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H1019	065	0	1	01	01	H1019_065_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					699.00	33																														33							33					33				33			33			
H1019	065	0	1	01	01	H1019_065_0	4	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H1026	001	0	1	01	01	H1026_001_0	9	5	Specialty Tier	3	4	100101	1	1	110100000010101000000111	31		90							1	31		90							31		31	14	31	14					1602.51	33		33																					33		33																	33				33			33	2	2	
H1026	001	0	1	01	01	H1026_001_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010101000000110	31		90							1	31		90							31		31	14				0.00		0.00																						0.00		0.00																		0.00					0.00							
H1026	001	0	1	01	01	H1026_001_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000110	31		90							1	31		90							31		31	14				0.00		0.00																						0.00		0.00																		0.00					0.00							
H1026	001	0	1	01	01	H1026_001_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		25.00		75.00																						25.00		75.00																		25.00								25.00				
H1026	001	0	1	01	01	H1026_001_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		50.00		150.00																						50.00		150.00																		50.00								50.00				
H1026	001	0	1	01	01	H1026_001_0	9	5	Specialty Tier	1	4	100101	1	1	110100000010101000000111	31		90							1	31		90							31		31	14	31	14					1602.51	33		33																					33		33																	33				33			33			
H1026	001	0	1	01	01	H1026_001_0	9	1	Preferred Generic	3	4	001000	1	2	010100000010101000000110	31		90							1	31		90							31		31	14				0.00		0.00																						0.00		0.00																		0.00					0.00					1		
H1026	001	0	1	01	01	H1026_001_0	9	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000110	31		90							1	31		90							31		31	14				0.00		0.00																						0.00		0.00																		0.00					0.00					1		
H1026	038	0	1	01	01	H1026_038_0	6	5	Specialty Tier	3	4	100101	1	1	110100000010101000000111	31		90							1	31		90							31		31	14	31	14					1602.51	33		33																					33		33																	33				33			33	2	2	
H1026	038	0	1	01	01	H1026_038_0	6	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000110	31		90							1	31		90							31		31	14				0.00		0.00																						0.00		0.00																		0.00					0.00					1		
H1026	038	0	1	01	01	H1026_038_0	6	1	Preferred Generic	3	4	001000	1	2	010100000010101000000110	31		90							1	31		90							31		31	14				0.00		0.00																						0.00		0.00																		0.00					0.00					1		
H1026	038	0	1	01	01	H1026_038_0	6	5	Specialty Tier	1	4	100101	1	1	110100000010101000000111	31		90							1	31		90							31		31	14	31	14					1602.51	33		33																					33		33																	33				33			33			
H1026	038	0	1	01	01	H1026_038_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		95.00		285.00																						95.00		285.00																		95.00								95.00				
H1026	038	0	1	01	01	H1026_038_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		45.00		135.00																						45.00		135.00																		45.00								45.00				
H1026	038	0	1	01	01	H1026_038_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000110	31		90							1	31		90							31		31	14				0.00		0.00																						0.00		0.00																		0.00					0.00							
H1026	038	0	1	01	01	H1026_038_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010101000000110	31		90							1	31		90							31		31	14				0.00		0.00																						0.00		0.00																		0.00					0.00							
H1026	040	0	1	01	01	H1026_040_0	6	5	Specialty Tier	3	4	100101	1	1	110100000010101000000111	31		90							1	31		90							31		31	14	31	14					1602.51	33		33																					33		33																	33				33			33	2	2	
H1026	040	0	1	01	01	H1026_040_0	6	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000110	31		90							1	31		90							31		31	14				0.00		0.00																						0.00		0.00																		0.00					0.00					1		
H1026	040	0	1	01	01	H1026_040_0	6	1	Preferred Generic	3	4	001000	1	2	010100000010101000000110	31		90							1	31		90							31		31	14				0.00		0.00																						0.00		0.00																		0.00					0.00					1		
H1026	040	0	1	01	01	H1026_040_0	6	5	Specialty Tier	1	4	100101	1	1	110100000010101000000111	31		90							1	31		90							31		31	14	31	14					1602.51	33		33																					33		33																	33				33			33			
H1026	040	0	1	01	01	H1026_040_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		95.00		285.00																						95.00		285.00																		95.00								95.00				
H1026	040	0	1	01	01	H1026_040_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		45.00		135.00																						45.00		135.00																		45.00								45.00				
H1026	040	0	1	01	01	H1026_040_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010101000000110	31		90							1	31		90							31		31	14				0.00		0.00																						0.00		0.00																		0.00					0.00							
H1026	040	0	1	01	01	H1026_040_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000110	31		90							1	31		90							31		31	14				0.00		0.00																						0.00		0.00																		0.00					0.00							
H1026	043	0	1	01	01	H1026_043_0	7	5	Specialty Tier	1	3	100101		1	110100000010101000000111	31		90							1	31		90							31		31	14	31	14					1602.51	33		33																					33		33																	33				33			33			
H1026	043	0	1	01	01	H1026_043_0	7	4	Non-Preferred Brand	1	3	100000		2	110100000010101000000001	31		90							1	31		90							31				31	14		95.00		285.00																						95.00		285.00																		95.00								95.00				
H1026	043	0	1	01	01	H1026_043_0	7	3	Preferred Brand	1	3	000001		2	110100000010101000000001	31		90							1	31		90							31				31	14		45.00		135.00																						45.00		135.00																		45.00								45.00				
H1026	043	0	1	01	01	H1026_043_0	7	2	Non-Preferred Generic	1	3	000100		2	010100000010101000000110	31		90							1	31		90							31		31	14				20.00		60.00																						0.00		0.00																		20.00					20.00							
H1026	043	0	1	01	01	H1026_043_0	7	1	Preferred Generic	1	3	001000	1	2	010100000010101000000110	31		90							1	31		90							31		31	14				10.00		30.00																						0.00		0.00																		10.00					10.00							
H1026	044	0	1	01	01	H1026_044_0	6	5	Specialty Tier	1	4	100101	1	1	110100000010101000000111	31		90							1	31		90							31		31	14	31	14					1602.51	33		33																					33		33																	33				33			33			
H1026	044	0	1	01	01	H1026_044_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		80.00		240.00																						80.00		240.00																		80.00								80.00				
H1026	044	0	1	01	01	H1026_044_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		30.00		90.00																						30.00		90.00																		30.00								30.00				
H1026	044	0	1	01	01	H1026_044_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000110	31		90							1	31		90							31		31	14				0.00		0.00																						0.00		0.00																		0.00					0.00							
H1026	044	0	1	01	01	H1026_044_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010101000000110	31		90							1	31		90							31		31	14				0.00		0.00																						0.00		0.00																		0.00					0.00							
H1026	044	0	1	01	01	H1026_044_0	6	1	Preferred Generic	3	4	001000	1	2	010100000010101000000110	31		90							1	31		90							31		31	14				0.00		0.00																						0.00		0.00																		0.00					0.00					1		
H1026	044	0	1	01	01	H1026_044_0	6	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000110	31		90							1	31		90							31		31	14				0.00		0.00																						0.00		0.00																		0.00					0.00					1		
H1026	044	0	1	01	01	H1026_044_0	6	5	Specialty Tier	3	4	100101	1	1	110100000010101000000111	31		90							1	31		90							31		31	14	31	14					1602.51	33		33																					33		33																	33				33			33	2	2	
H1026	045	0	1	01	01	H1026_045_0	6	3	Preferred Brand	1	3	000001		2	110100000010101000000001	31		90							1	31		90							31				31	14		45.00		135.00																						45.00		135.00																		45.00								45.00				
H1026	045	0	1	01	01	H1026_045_0	6	1	Preferred Generic	1	3	001000	1	2	010100000010101000000110	31		90							1	31		90							31		31	14				10.00		30.00																						0.00		0.00																		10.00					10.00							
H1026	045	0	1	01	01	H1026_045_0	6	2	Non-Preferred Generic	1	3	000100		2	010100000010101000000110	31		90							1	31		90							31		31	14				20.00		60.00																						0.00		0.00																		20.00					20.00							
H1026	045	0	1	01	01	H1026_045_0	6	4	Non-Preferred Brand	1	3	100000		2	110100000010101000000001	31		90							1	31		90							31				31	14		95.00		285.00																						95.00		285.00																		95.00								95.00				
H1026	045	0	1	01	01	H1026_045_0	6	5	Specialty Tier	1	3	100101		1	110100000010101000000111	31		90							1	31		90							31		31	14	31	14					1602.51	33		33																					33		33																	33				33			33			
H1026	046	0	1	01	01	H1026_046_0	7	5	Specialty Tier	3	4	100101	1	1	110100000010101000000111	31		90							1	31		90							31		31	14	31	14					1602.51	33		33																					33		33																	33				33			33	2	2	
H1026	046	0	1	01	01	H1026_046_0	7	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000110	31		90							1	31		90							31		31	14				0.00		0.00																						0.00		0.00																		0.00					0.00					1		
H1026	046	0	1	01	01	H1026_046_0	7	5	Specialty Tier	1	4	100101	1	1	110100000010101000000111	31		90							1	31		90							31		31	14	31	14					1602.51	33		33																					33		33																	33				33			33			
H1026	046	0	1	01	01	H1026_046_0	7	1	Preferred Generic	3	4	001000	1	2	010100000010101000000110	31		90							1	31		90							31		31	14				0.00		0.00																						0.00		0.00																		0.00					0.00					1		
H1026	046	0	1	01	01	H1026_046_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010101000000110	31		90							1	31		90							31		31	14				0.00		0.00																						0.00		0.00																		0.00					0.00							
H1026	046	0	1	01	01	H1026_046_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000110	31		90							1	31		90							31		31	14				0.00		0.00																						0.00		0.00																		0.00					0.00							
H1026	046	0	1	01	01	H1026_046_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		45.00		135.00																						45.00		135.00																		45.00								45.00				
H1026	046	0	1	01	01	H1026_046_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		95.00		285.00																						95.00		285.00																		95.00								95.00				
H1032	002	0	1	02	01	H1032_002_0	6	4	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
H1032	002	0	1	02	01	H1032_002_0	6	3	Non-Preferred Brand	1	4	100000	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		60.00	120.00	180.00																													60.00	120.00	120.00							180.00				60.00								60.00				
H1032	002	0	1	02	01	H1032_002_0	6	2	Preferred Brand	1	4	000001	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		25.00	50.00	75.00																													25.00	50.00	50.00							75.00				25.00								25.00				
H1032	002	0	1	02	01	H1032_002_0	6	1	Generic	3	4	010010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		3.00	6.00	9.00																													3.00	6.00	0.00							9.00				3.00					3.00			3.00		1		
H1032	002	0	1	02	01	H1032_002_0	6	1	Generic	1	4	010010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
H1032	008	0	1	01	01	H1032_008_0	7	1	Generic	1	4	010010	3	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
H1032	008	0	1	01	01	H1032_008_0	7	3	Non-Preferred Brand	1	4	100000	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		30.00	60.00	90.00																													30.00	60.00	60.00							90.00				30.00								30.00				
H1032	008	0	1	01	01	H1032_008_0	7	4	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
H1032	008	0	1	01	01	H1032_008_0	7	1	Generic	3	4	010010	3	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00		1		
H1032	008	0	1	01	01	H1032_008_0	7	2	Preferred Brand	1	4	000001	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00								0.00				
H1032	008	0	1	01	01	H1032_008_0	7	2	Preferred Brand	3	4	000001	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00								0.00		1		
H1032	008	0	1	01	01	H1032_008_0	7	3	Non-Preferred Brand	3	4	100000	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		30.00	60.00	90.00																													30.00	60.00	60.00							90.00				30.00								30.00		1		
H1032	008	0	1	01	01	H1032_008_0	7	4	Specialty Tier	3	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33	1		
H1032	025	0	1	02	01	H1032_025_0	7	1	Generic	1	4	010010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		3.00	6.00	9.00																													3.00	6.00	0.00							9.00				3.00					3.00			3.00				
H1032	025	0	1	02	01	H1032_025_0	7	2	Preferred Brand	1	4	000001	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		39.00	78.00	117.00																													39.00	78.00	78.00							117.00				39.00								39.00				
H1032	025	0	1	02	01	H1032_025_0	7	3	Non-Preferred Brand	1	4	100000	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		75.00	150.00	225.00																													75.00	150.00	150.00							225.00				75.00								75.00				
H1032	025	0	1	02	01	H1032_025_0	7	4	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
H1032	032	0	1	01	01	H1032_032_0	6	4	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
H1032	032	0	1	01	01	H1032_032_0	6	3	Non-Preferred Brand	1	4	100000	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		55.00	110.00	165.00																													55.00	110.00	110.00							165.00				55.00								55.00				
H1032	032	0	1	01	01	H1032_032_0	6	1	Generic	3	4	010010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		3.00	6.00	9.00																													3.00	6.00	0.00							9.00				3.00					3.00			3.00		1		
H1032	032	0	1	01	01	H1032_032_0	6	2	Preferred Brand	1	4	000001	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		20.00	40.00	60.00																													20.00	40.00	40.00							60.00				20.00								20.00				
H1032	032	0	1	01	01	H1032_032_0	6	1	Generic	1	4	010010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
H1032	035	0	1	02	01	H1032_035_0	6	1	Generic	1	4	010010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
H1032	035	0	1	02	01	H1032_035_0	6	2	Preferred Brand	1	4	000001	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		20.00	40.00	60.00																													20.00	40.00	40.00							60.00				20.00								20.00				
H1032	035	0	1	02	01	H1032_035_0	6	3	Non-Preferred Brand	1	4	100000	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		55.00	110.00	165.00																													55.00	110.00	110.00							165.00				55.00								55.00				
H1032	035	0	1	02	01	H1032_035_0	6	4	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
H1032	035	0	1	02	01	H1032_035_0	6	1	Generic	3	4	010010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		3.00	6.00	9.00																													3.00	6.00	0.00							9.00				3.00					3.00			3.00		1		
H1032	040	0	1	01	01	H1032_040_0	7	1	Generic	3	4	010010	3	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		3.00	6.00	9.00																													3.00	6.00	0.00							9.00				3.00					3.00			3.00		1		
H1032	040	0	1	01	01	H1032_040_0	7	4	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
H1032	040	0	1	01	01	H1032_040_0	7	1	Generic	1	4	010010	3	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
H1032	040	0	1	01	01	H1032_040_0	7	2	Preferred Brand	1	4	000001	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		25.00	50.00	75.00																													25.00	50.00	50.00							75.00				25.00								25.00				
H1032	040	0	1	01	01	H1032_040_0	7	3	Non-Preferred Brand	1	4	100000	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		49.00	98.00	147.00																													49.00	98.00	98.00							147.00				49.00								49.00				
H1032	061	0	1	02	01	H1032_061_0	7	3	Non-Preferred Brand	1	4	100000	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		95.00	190.00	285.00																													95.00	190.00	190.00							285.00				95.00								95.00				
H1032	061	0	1	02	01	H1032_061_0	7	4	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					707.00	25																														25							25					25							25			
H1032	061	0	1	02	01	H1032_061_0	7	1	Generic	1	4	010010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
H1032	061	0	1	02	01	H1032_061_0	7	2	Preferred Brand	1	4	000001	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		45.00	90.00	135.00																													45.00	90.00	90.00							135.00				45.00								45.00				
H1032	073	0	1	02	01	H1032_073_0	7	4	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
H1032	073	0	1	02	01	H1032_073_0	7	3	Non-Preferred Brand	1	4	100000	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		79.00	158.00	237.00																													79.00	158.00	158.00							237.00				79.00								79.00				
H1032	073	0	1	02	01	H1032_073_0	7	1	Generic	1	4	010010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
H1032	073	0	1	02	01	H1032_073_0	7	2	Preferred Brand	1	4	000001	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		30.00	60.00	90.00																													30.00	60.00	60.00							90.00				30.00								30.00				
H1032	079	0	1	01	01	H1032_079_0	7	3	Non-Preferred Brand	1	4	100000	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		79.00	158.00	237.00																													79.00	158.00	158.00							237.00				79.00								79.00				
H1032	079	0	1	01	01	H1032_079_0	7	2	Preferred Brand	1	4	000001	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		39.00	78.00	117.00																													39.00	78.00	78.00							117.00				39.00								39.00				
H1032	079	0	1	01	01	H1032_079_0	7	1	Generic	1	4	010010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		3.00	6.00	9.00																													3.00	6.00	0.00							9.00				3.00					3.00			3.00				
H1032	079	0	1	01	01	H1032_079_0	7	4	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
H1032	091	0	1	02	01	H1032_091_0	6	4	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
H1032	091	0	1	02	01	H1032_091_0	6	3	Non-Preferred Brand	1	4	100000	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		60.00	120.00	180.00																													60.00	120.00	120.00							180.00				60.00								60.00				
H1032	091	0	1	02	01	H1032_091_0	6	2	Preferred Brand	1	4	000001	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		25.00	50.00	75.00																													25.00	50.00	50.00							75.00				25.00								25.00				
H1032	091	0	1	02	01	H1032_091_0	6	1	Generic	1	4	010010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
H1032	101	0	1	02	01	H1032_101_0	7	1	Generic	1	4	010010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
H1032	101	0	1	02	01	H1032_101_0	7	2	Preferred Brand	1	4	000001	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		45.00	90.00	135.00																													45.00	90.00	90.00							135.00				45.00								45.00				
H1032	101	0	1	02	01	H1032_101_0	7	3	Non-Preferred Brand	1	4	100000	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		95.00	190.00	285.00																													95.00	190.00	190.00							285.00				95.00								95.00				
H1032	101	0	1	02	01	H1032_101_0	7	4	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					707.00	25																														25							25					25							25			
H1032	124	0	1	01	01	H1032_124_0	6	1	Generic	1	4	010010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
H1032	124	0	1	01	01	H1032_124_0	6	4	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					707.00	25																														25							25					25							25			
H1032	124	0	1	01	01	H1032_124_0	6	3	Non-Preferred Brand	1	4	100000	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		95.00	190.00	285.00																													95.00	190.00	190.00							285.00				95.00								95.00				
H1032	124	0	1	01	01	H1032_124_0	6	2	Preferred Brand	1	4	000001	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		45.00	90.00	135.00																													45.00	90.00	90.00							135.00				45.00								45.00				
H1032	133	0	1	01	01	H1032_133_0	7	2	Preferred Brand	1	4	000001	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		39.00	78.00	117.00																													39.00	78.00	78.00							117.00				39.00								39.00				
H1032	133	0	1	01	01	H1032_133_0	7	3	Non-Preferred Brand	1	4	100000	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		79.00	158.00	237.00																													79.00	158.00	158.00							237.00				79.00								79.00				
H1032	133	0	1	01	01	H1032_133_0	7	4	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
H1032	133	0	1	01	01	H1032_133_0	7	1	Generic	3	4	010010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		3.00	6.00	9.00																													3.00	6.00	0.00							9.00				3.00					3.00			3.00		1		
H1032	133	0	1	01	01	H1032_133_0	7	1	Generic	1	4	010010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
H1032	170	0	1	01	01	H1032_170_0	6	2	Preferred Brand	1	4	000001	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00								0.00				
H1032	170	0	1	01	01	H1032_170_0	6	1	Generic	3	4	010010	3	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00		1		
H1032	170	0	1	01	01	H1032_170_0	6	4	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
H1032	170	0	1	01	01	H1032_170_0	6	3	Non-Preferred Brand	1	4	100000	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		30.00	60.00	90.00																													30.00	60.00	60.00							90.00				30.00								30.00				
H1032	170	0	1	01	01	H1032_170_0	6	2	Preferred Brand	3	4	000001	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00								0.00		1		
H1032	170	0	1	01	01	H1032_170_0	6	1	Generic	1	4	010010	3	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
H1032	173	0	1	01	01	H1032_173_0	7	1	Generic	1	4	010010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
H1032	173	0	1	01	01	H1032_173_0	7	2	Preferred Brand	1	4	000001	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		35.00	70.00	105.00																													35.00	70.00	70.00							105.00				35.00								35.00				
H1032	173	0	1	01	01	H1032_173_0	7	3	Non-Preferred Brand	1	4	100000	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		75.00	150.00	225.00																													75.00	150.00	150.00							225.00				75.00								75.00				
H1032	173	0	1	01	01	H1032_173_0	7	4	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
H1032	173	0	1	01	01	H1032_173_0	7	1	Generic	3	4	010010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		3.00	6.00	9.00																													3.00	6.00	0.00							9.00				3.00					3.00			3.00		1		
H1032	174	0	1	01	01	H1032_174_0	7	1	Generic	1	4	010010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
H1032	174	0	1	01	01	H1032_174_0	7	2	Preferred Brand	1	4	000001	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		20.00	40.00	60.00																													20.00	40.00	40.00							60.00				20.00								20.00				
H1032	174	0	1	01	01	H1032_174_0	7	3	Non-Preferred Brand	1	4	100000	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		60.00	120.00	180.00																													60.00	120.00	120.00							180.00				60.00								60.00				
H1032	174	0	1	01	01	H1032_174_0	7	1	Generic	3	4	010010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		3.00	6.00	9.00																													3.00	6.00	0.00							9.00				3.00					3.00			3.00		1		
H1032	174	0	1	01	01	H1032_174_0	7	4	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
H1032	175	0	1	01	01	H1032_175_0	6	4	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					707.00	25																														25							25					25							25			
H1032	175	0	1	01	01	H1032_175_0	6	3	Non-Preferred Brand	1	4	100000	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		95.00	190.00	285.00																													95.00	190.00	190.00							285.00				95.00								95.00				
H1032	175	0	1	01	01	H1032_175_0	6	1	Generic	1	4	010010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
H1032	175	0	1	01	01	H1032_175_0	6	2	Preferred Brand	1	4	000001	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		45.00	90.00	135.00																													45.00	90.00	90.00							135.00				45.00								45.00				
H1032	176	0	1	01	01	H1032_176_0	6	4	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
H1032	176	0	1	01	01	H1032_176_0	6	3	Non-Preferred Brand	1	4	100000	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		30.00	60.00	90.00																													30.00	60.00	60.00							90.00				30.00								30.00				
H1032	176	0	1	01	01	H1032_176_0	6	2	Preferred Brand	1	4	000001	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00								0.00				
H1032	176	0	1	01	01	H1032_176_0	6	1	Generic	3	4	010010	3	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00		1		
H1032	176	0	1	01	01	H1032_176_0	6	2	Preferred Brand	3	4	000001	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00								0.00		1		
H1032	176	0	1	01	01	H1032_176_0	6	1	Generic	1	4	010010	3	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
H1032	177	0	1	02	01	H1032_177_0	6	4	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
H1032	177	0	1	02	01	H1032_177_0	6	3	Non-Preferred Brand	1	4	100000	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		60.00	120.00	180.00																													60.00	120.00	120.00							180.00				60.00								60.00				
H1032	177	0	1	02	01	H1032_177_0	6	2	Preferred Brand	1	4	000001	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		25.00	50.00	75.00																													25.00	50.00	50.00							75.00				25.00								25.00				
H1032	177	0	1	02	01	H1032_177_0	6	1	Generic	1	4	010010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
H1032	179	0	1	01	01	H1032_179_0	8	4	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
H1032	179	0	1	01	01	H1032_179_0	8	3	Non-Preferred Brand	1	4	100000	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		75.00	150.00	225.00																													75.00	150.00	150.00							225.00				75.00								75.00				
H1032	179	0	1	01	01	H1032_179_0	8	2	Preferred Brand	1	4	000001	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		39.00	78.00	117.00																													39.00	78.00	78.00							117.00				39.00								39.00				
H1032	179	0	1	01	01	H1032_179_0	8	1	Generic	1	4	010010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		3.00	6.00	9.00																													3.00	6.00	0.00							9.00				3.00					3.00			3.00				
H1032	179	0	1	01	01	H1032_179_0	8	1	Generic	3	4	010010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		3.00	6.00	9.00																													3.00	6.00	0.00							9.00				3.00					3.00			3.00		1		
H1035	002	0	1	02	01	H1035_002_0	9	6	Injectable Drugs	1	4	010010	1	1	100010110110001000000101				31		93	31		93	1			93							31		31		31	14													55.19	25		25					55.19	25		25							25																	25				25			25			
H1035	002	0	1	02	01	H1035_002_0	9	4	Non-Preferred Brand	1	4	100000	1	1	100010110110001000000001				31		93	31		93	1			93							31				31	14													83.81	50		50					100.27	50		50							50																	50							50			
H1035	002	0	1	02	01	H1035_002_0	9	3	Preferred Brand	1	4	000001	1	1	100010110110001000000001				31		93	31		93	1			93							31				31	14													20.51	25		25					30.29	25		25							25																	25							25			
H1035	002	0	1	02	01	H1035_002_0	9	2	Non-Preferred Generic	1	4	000100	1	2	000010110110001000000100				31		93	31		93	1			93							31		31													4.00		12.00						17.00		51.00								9.00																		17.00					17.00							
H1035	002	0	1	02	01	H1035_002_0	9	1	Preferred Generic	1	4	001000	1	2	000010110110001000000100				31		93	31		93	1			93							31		31													0.00		0.00						10.00		30.00								0.00																		10.00					10.00							
H1035	002	0	1	02	01	H1035_002_0	9	2	Non-Preferred Generic	3	4	000100	1	2	000010110110001000000100				31		93	31		93	1			93							31		31													4.00		12.00						17.00		51.00								9.00																		17.00					17.00					1		
H1035	002	0	1	02	01	H1035_002_0	9	5	Specialty Tier	1	4	010010	1	1	100010010010000000000101				31			31													31		31		31	14													1411.82	33							2155.87	33																										33				33			33			
H1035	002	0	1	02	01	H1035_002_0	9	1	Preferred Generic	3	4	001000	1	2	000010110110001000000100				31		93	31		93	1			93							31		31													0.00		0.00						10.00		30.00								0.00																		10.00					10.00					1		
H1035	006	0	1	01	01	H1035_006_0	10	6	Injectable Drugs	1	4	010010	1	1	100010110110001000000101				31		93	31		93	1			93							31		31		31	14													75.18	25		25					75.18	25		25							25																	25				25			25			
H1035	006	0	1	01	01	H1035_006_0	10	5	Specialty Tier	1	4	010010	1	1	100010010010000000000101				31			31													31		31		31	14													780.22	29							780.22	29																										29				29			29			
H1035	006	0	1	01	01	H1035_006_0	10	4	Non-Preferred Brand	1	4	100000	1	2	100010110110001000000001				31		93	31		93	1			93							31				31	14										70.00		210.00						90.00		270.00								207.00																		90.00								90.00				
H1035	006	0	1	01	01	H1035_006_0	10	3	Preferred Brand	1	4	000001	1	2	100010110110001000000001				31		93	31		93	1			93							31				31	14										40.00		120.00						45.00		135.00								117.00																		45.00								45.00				
H1035	006	0	1	01	01	H1035_006_0	10	2	Non-Preferred Generic	1	4	000100	1	2	000010110110001000000100				31		93	31		93	1			93							31		31													7.00		21.00						17.00		51.00								18.00																		17.00					17.00							
H1035	006	0	1	01	01	H1035_006_0	10	1	Preferred Generic	1	4	001000	1	2	000010110110001000000100				31		93	31		93	1			93							31		31													2.00		6.00						10.00		30.00								3.00																		10.00					10.00							
H1036	025	0	1	01	01	H1036_025_0	6	1	Preferred Generic	1	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	025	0	1	01	01	H1036_025_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	025	0	1	01	01	H1036_025_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	025	0	1	01	01	H1036_025_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		55.00		165.00																													55.00		155.00					55.00		165.00				55.00					55.00			55.00				
H1036	025	0	1	01	01	H1036_025_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					809.00	33																														33							33					33				33			33	2	1	
H1036	025	0	1	01	01	H1036_025_0	6	1	Preferred Generic	3	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1036	025	0	1	01	01	H1036_025_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1036	025	0	1	01	01	H1036_025_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	
H1036	025	0	1	01	01	H1036_025_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		55.00		165.00																													55.00		155.00					55.00		165.00				55.00					55.00			55.00		2	3	
H1036	025	0	1	01	01	H1036_025_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					719.00	33																														33							33					33				33			33			
H1036	040	0	1	01	01	H1036_040_0	4	1	Preferred Generic	1	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	040	0	1	01	01	H1036_040_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	040	0	1	01	01	H1036_040_0	4	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					816.00	33																														33							33					33				33			33	2	1	
H1036	040	0	1	01	01	H1036_040_0	4	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		55.00		165.00																													55.00		155.00					55.00		165.00				55.00					55.00			55.00		2	3	
H1036	040	0	1	01	01	H1036_040_0	4	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	
H1036	040	0	1	01	01	H1036_040_0	4	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1036	040	0	1	01	01	H1036_040_0	4	1	Preferred Generic	3	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1036	040	0	1	01	01	H1036_040_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					670.00	33																														33							33					33				33			33			
H1036	040	0	1	01	01	H1036_040_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		55.00		165.00																													55.00		155.00					55.00		165.00				55.00					55.00			55.00				
H1036	040	0	1	01	01	H1036_040_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	044	0	1	01	01	H1036_044_0	3	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	044	0	1	01	01	H1036_044_0	3	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H1036	044	0	1	01	01	H1036_044_0	3	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	3	
H1036	044	0	1	01	01	H1036_044_0	3	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	
H1036	044	0	1	01	01	H1036_044_0	3	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					812.00	33																														33							33					33				33			33	2	1	
H1036	044	0	1	01	01	H1036_044_0	3	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					724.00	33																														33							33					33				33			33			
H1036	044	0	1	01	01	H1036_044_0	3	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H1036	044	0	1	01	01	H1036_044_0	3	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H1036	044	0	1	01	01	H1036_044_0	3	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	044	0	1	01	01	H1036_044_0	3	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	1
H1036	052	0	1	01	01	H1036_052_0	5	1	Preferred Generic	1	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		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	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		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	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					939.00	33																														33							33					33				33			33	2	1	
H1036	052	0	1	01	01	H1036_052_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		55.00		165.00																													55.00		155.00					55.00		165.00				55.00					55.00			55.00		2	3	
H1036	052	0	1	01	01	H1036_052_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	
H1036	052	0	1	01	01	H1036_052_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1036	052	0	1	01	01	H1036_052_0	5	1	Preferred Generic	3	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1036	052	0	1	01	01	H1036_052_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					760.00	33																														33							33					33				33			33			
H1036	052	0	1	01	01	H1036_052_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		55.00		165.00																													55.00		155.00					55.00		165.00				55.00					55.00			55.00				
H1036	052	0	1	01	01	H1036_052_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	054	0	1	01	01	H1036_054_0	6	1	Preferred Generic	1	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	054	0	1	01	01	H1036_054_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		25.00		75.00																													25.00		65.00					25.00		75.00				25.00					25.00			25.00		2	3	
H1036	054	0	1	01	01	H1036_054_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	
H1036	054	0	1	01	01	H1036_054_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1036	054	0	1	01	01	H1036_054_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					746.00	33																														33							33					33				33			33	2	1	
H1036	054	0	1	01	01	H1036_054_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					402.00	33																														33							33					33				33			33			
H1036	054	0	1	01	01	H1036_054_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		25.00		75.00																													25.00		65.00					25.00		75.00				25.00					25.00			25.00				
H1036	054	0	1	01	01	H1036_054_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	054	0	1	01	01	H1036_054_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	054	0	1	01	01	H1036_054_0	6	1	Preferred Generic	3	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1036	062	0	1	01	01	H1036_062_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		35.00		105.00																													35.00		95.00					35.00		105.00				35.00					35.00			35.00				
H1036	062	0	1	01	01	H1036_062_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		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	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					612.00	33																														33							33					33				33			33	2	1	
H1036	062	0	1	01	01	H1036_062_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H1036	062	0	1	01	01	H1036_062_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		35.00		105.00																													35.00		95.00					35.00		105.00				35.00					35.00			35.00		2	3	
H1036	062	0	1	01	01	H1036_062_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1036	062	0	1	01	01	H1036_062_0	5	1	Preferred Generic	3	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1036	062	0	1	01	01	H1036_062_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					545.00	33																														33							33					33				33			33			
H1036	062	0	1	01	01	H1036_062_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H1036	062	0	1	01	01	H1036_062_0	5	1	Preferred Generic	1	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		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	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													7.00		11.00					7.00		21.00				7.00					7.00			7.00		2	3	
H1036	065	0	1	01	01	H1036_065_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	3	
H1036	065	0	1	01	01	H1036_065_0	6	1	Preferred Generic	3	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1036	065	0	1	01	01	H1036_065_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1036	065	0	1	01	01	H1036_065_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					544.00	33																														33							33					33				33			33			
H1036	065	0	1	01	01	H1036_065_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1036	065	0	1	01	01	H1036_065_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													7.00		11.00					7.00		21.00				7.00					7.00			7.00				
H1036	065	0	1	01	01	H1036_065_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		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	6	1	Preferred Generic	1	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		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	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					695.00	33																														33							33					33				33			33	2	1	
H1036	067	0	1	01	01	H1036_067_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		55.00		165.00																													55.00		155.00					55.00		165.00				55.00					55.00			55.00		2	3	
H1036	067	0	1	01	01	H1036_067_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	
H1036	067	0	1	01	01	H1036_067_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1036	067	0	1	01	01	H1036_067_0	5	1	Preferred Generic	3	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1036	067	0	1	01	01	H1036_067_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		55.00		165.00																													55.00		155.00					55.00		165.00				55.00					55.00			55.00				
H1036	067	0	1	01	01	H1036_067_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		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	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		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	1	Preferred Generic	1	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		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	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					634.00	33																														33							33					33				33			33	2	1	
H1036	067	0	1	01	01	H1036_067_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					490.00	33																														33							33					33				33			33			
H1036	068	0	1	01	01	H1036_068_0	3	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H1036	068	0	1	01	01	H1036_068_0	3	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00				
H1036	068	0	1	01	01	H1036_068_0	3	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	068	0	1	01	01	H1036_068_0	3	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					887.00	33																														33							33					33				33			33	2	1	
H1036	068	0	1	01	01	H1036_068_0	3	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00		2	3	
H1036	068	0	1	01	01	H1036_068_0	3	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H1036	068	0	1	01	01	H1036_068_0	3	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00		2	2	
H1036	068	0	1	01	01	H1036_068_0	3	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00				
H1036	068	0	1	01	01	H1036_068_0	3	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					702.00	33																														33							33					33				33			33			
H1036	068	0	1	01	01	H1036_068_0	3	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	1
H1036	074	0	1	01	01	H1036_074_0	5	1	Preferred Generic	1	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	074	0	1	01	01	H1036_074_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	074	0	1	01	01	H1036_074_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	074	0	1	01	01	H1036_074_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		55.00		165.00																													55.00		155.00					55.00		165.00				55.00					55.00			55.00				
H1036	074	0	1	01	01	H1036_074_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					472.00	33																														33							33					33				33			33	2	1	
H1036	074	0	1	01	01	H1036_074_0	5	1	Preferred Generic	3	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1036	074	0	1	01	01	H1036_074_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1036	074	0	1	01	01	H1036_074_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	
H1036	074	0	1	01	01	H1036_074_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		55.00		165.00																													55.00		155.00					55.00		165.00				55.00					55.00			55.00		2	3	
H1036	074	0	1	01	01	H1036_074_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					419.00	33																														33							33					33				33			33			
H1036	077	0	1	01	01	H1036_077_0	4	1	Preferred Generic	1	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		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	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		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	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1036	077	0	1	01	01	H1036_077_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1036	077	0	1	01	01	H1036_077_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					480.00	25																														25							25					25				25			25			
H1036	081	0	1	01	01	H1036_081_0	3	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	081	0	1	01	01	H1036_081_0	3	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00				
H1036	081	0	1	01	01	H1036_081_0	3	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1036	081	0	1	01	01	H1036_081_0	3	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00				
H1036	081	0	1	01	01	H1036_081_0	3	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					934.00	33																														33							33					33				33			33	2	3	
H1036	081	0	1	01	01	H1036_081_0	3	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	1
H1036	081	0	1	01	01	H1036_081_0	3	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00		2	2	
H1036	081	0	1	01	01	H1036_081_0	3	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H1036	081	0	1	01	01	H1036_081_0	3	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00		2	3	
H1036	081	0	1	01	01	H1036_081_0	3	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					844.00	33																														33							33					33				33			33			
H1036	102	0	1	01	01	H1036_102_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					540.00	25																														25							25					25				25			25			
H1036	102	0	1	01	01	H1036_102_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	102	0	1	01	01	H1036_102_0	4	1	Preferred Generic	1	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	102	0	1	01	01	H1036_102_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1036	102	0	1	01	01	H1036_102_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1036	103	0	1	01	01	H1036_103_0	4	1	Preferred Generic	1	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		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	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		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	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1036	103	0	1	01	01	H1036_103_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1036	103	0	1	01	01	H1036_103_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					440.00	25																														25							25					25				25			25			
H1036	104	0	1	01	01	H1036_104_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					389.00	25																														25							25					25				25			25			
H1036	104	0	1	01	01	H1036_104_0	4	1	Preferred Generic	1	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	104	0	1	01	01	H1036_104_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	104	0	1	01	01	H1036_104_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1036	104	0	1	01	01	H1036_104_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1036	121	0	1	01	01	H1036_121_0	4	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1036	121	0	1	01	01	H1036_121_0	4	1	Preferred Generic	3	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1036	121	0	1	01	01	H1036_121_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					630.00	33																														33							33					33				33			33			
H1036	121	0	1	01	01	H1036_121_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1036	121	0	1	01	01	H1036_121_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													10.00		20.00					10.00		30.00				10.00					10.00			10.00				
H1036	121	0	1	01	01	H1036_121_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		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	4	1	Preferred Generic	1	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		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	4	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					743.00	33																														33							33					33				33			33	2	1	
H1036	121	0	1	01	01	H1036_121_0	4	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													10.00		20.00					10.00		30.00				10.00					10.00			10.00		2	3	
H1036	121	0	1	01	01	H1036_121_0	4	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	3	
H1036	130	0	1	01	01	H1036_130_0	4	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					839.00	33																														33							33					33				33			33	2	1	
H1036	130	0	1	01	01	H1036_130_0	4	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		35.00		105.00																													35.00		95.00					35.00		105.00				35.00					35.00			35.00		2	3	
H1036	130	0	1	01	01	H1036_130_0	4	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H1036	130	0	1	01	01	H1036_130_0	4	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1036	130	0	1	01	01	H1036_130_0	4	1	Preferred Generic	3	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1036	130	0	1	01	01	H1036_130_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					815.00	33																														33							33					33				33			33			
H1036	130	0	1	01	01	H1036_130_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H1036	130	0	1	01	01	H1036_130_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		35.00		105.00																													35.00		95.00					35.00		105.00				35.00					35.00			35.00				
H1036	130	0	1	01	01	H1036_130_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		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	4	1	Preferred Generic	1	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	136	0	1	01	01	H1036_136_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00				
H1036	136	0	1	01	01	H1036_136_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H1036	136	0	1	01	01	H1036_136_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1036	136	0	1	01	01	H1036_136_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H1036	136	0	1	01	01	H1036_136_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1013.00	33																														33							33					33				33			33	2	3	
H1036	136	0	1	01	01	H1036_136_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00		2	3	1
H1036	136	0	1	01	01	H1036_136_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H1036	136	0	1	01	01	H1036_136_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H1036	136	0	1	01	01	H1036_136_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H1036	136	0	1	01	01	H1036_136_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					889.00	33																														33							33					33				33			33			
H1036	137	0	1	02	01	H1036_137_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H1036	137	0	1	02	01	H1036_137_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H1036	137	0	1	02	01	H1036_137_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H1036	137	0	1	02	01	H1036_137_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					711.00	33																														33							33					33				33			33	2	3	
H1036	137	0	1	02	01	H1036_137_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H1036	137	0	1	02	01	H1036_137_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H1036	137	0	1	02	01	H1036_137_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1036	137	0	1	02	01	H1036_137_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H1036	137	0	1	02	01	H1036_137_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					682.00	33																														33							33					33				33			33			
H1036	137	0	1	02	01	H1036_137_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	
H1036	138	0	1	02	01	H1036_138_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		3.00		9.00																													0.00		0.00					3.00		9.00				3.00					3.00			3.00				
H1036	138	0	1	02	01	H1036_138_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H1036	138	0	1	02	01	H1036_138_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1036	138	0	1	02	01	H1036_138_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H1036	138	0	1	02	01	H1036_138_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1022.00	33																														33							33					33				33			33	2	3	
H1036	138	0	1	02	01	H1036_138_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		3.00		9.00																													0.00		0.00					3.00		9.00				3.00					3.00			3.00		2	3	
H1036	138	0	1	02	01	H1036_138_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H1036	138	0	1	02	01	H1036_138_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H1036	138	0	1	02	01	H1036_138_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H1036	138	0	1	02	01	H1036_138_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					891.00	33																														33							33					33				33			33			
H1036	140	0	1	01	01	H1036_140_0	3	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	140	0	1	01	01	H1036_140_0	3	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H1036	140	0	1	01	01	H1036_140_0	3	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					742.00	33																														33							33					33				33			33	2	1	
H1036	140	0	1	01	01	H1036_140_0	3	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		75.00		225.00																													75.00		215.00					75.00		225.00				75.00					75.00			75.00		2	3	
H1036	140	0	1	01	01	H1036_140_0	3	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H1036	140	0	1	01	01	H1036_140_0	3	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H1036	140	0	1	01	01	H1036_140_0	3	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	1
H1036	140	0	1	01	01	H1036_140_0	3	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					611.00	33																														33							33					33				33			33			
H1036	140	0	1	01	01	H1036_140_0	3	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		75.00		225.00																													75.00		215.00					75.00		225.00				75.00					75.00			75.00				
H1036	140	0	1	01	01	H1036_140_0	3	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H1036	141	0	1	01	01	H1036_141_0	4	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1080.00	33																														33							33					33				33			33	2	1	
H1036	141	0	1	01	01	H1036_141_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	141	0	1	01	01	H1036_141_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		25.00		75.00																													25.00		65.00					25.00		75.00				25.00					25.00			25.00				
H1036	141	0	1	01	01	H1036_141_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		55.00		165.00																													55.00		155.00					55.00		165.00				55.00					55.00			55.00				
H1036	141	0	1	01	01	H1036_141_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	141	0	1	01	01	H1036_141_0	4	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	1
H1036	141	0	1	01	01	H1036_141_0	4	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	2	
H1036	141	0	1	01	01	H1036_141_0	4	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		25.00		75.00																													25.00		65.00					25.00		75.00				25.00					25.00			25.00		2	2	
H1036	141	0	1	01	01	H1036_141_0	4	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		55.00		165.00																													55.00		155.00					55.00		165.00				55.00					55.00			55.00		2	3	
H1036	141	0	1	01	01	H1036_141_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					836.00	33																														33							33					33				33			33			
H1036	143	0	1	01	01	H1036_143_0	4	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H1036	143	0	1	01	01	H1036_143_0	4	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					581.00	33																														33							33					33				33			33	2	1	
H1036	143	0	1	01	01	H1036_143_0	4	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	3	
H1036	143	0	1	01	01	H1036_143_0	4	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	
H1036	143	0	1	01	01	H1036_143_0	4	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	1
H1036	143	0	1	01	01	H1036_143_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					443.00	33																														33							33					33				33			33			
H1036	143	0	1	01	01	H1036_143_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H1036	143	0	1	01	01	H1036_143_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H1036	143	0	1	01	01	H1036_143_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H1036	143	0	1	01	01	H1036_143_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	146	0	1	01	01	H1036_146_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	146	0	1	01	01	H1036_146_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H1036	146	0	1	01	01	H1036_146_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					690.00	33																														33							33					33				33			33			
H1036	146	0	1	01	01	H1036_146_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1036	146	0	1	01	01	H1036_146_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1036	146	0	1	01	01	H1036_146_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		20.00		60.00																													20.00		50.00					20.00		60.00				20.00					20.00			20.00		2	2	
H1036	146	0	1	01	01	H1036_146_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H1036	146	0	1	01	01	H1036_146_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					824.00	33																														33							33					33				33			33	2	1	
H1036	146	0	1	01	01	H1036_146_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		20.00		60.00																													20.00		50.00					20.00		60.00				20.00					20.00			20.00				
H1036	146	0	1	01	01	H1036_146_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	149	0	1	02	01	H1036_149_0	8	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					975.00	33																														33							33					33				33			33	2	3	
H1036	149	0	1	02	01	H1036_149_0	8	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H1036	149	0	1	02	01	H1036_149_0	8	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H1036	149	0	1	02	01	H1036_149_0	8	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H1036	149	0	1	02	01	H1036_149_0	8	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					822.00	33																														33							33					33				33			33			
H1036	149	0	1	02	01	H1036_149_0	8	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H1036	149	0	1	02	01	H1036_149_0	8	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H1036	149	0	1	02	01	H1036_149_0	8	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H1036	151	0	1	01	01	H1036_151_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1036	151	0	1	01	01	H1036_151_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1036	151	0	1	01	01	H1036_151_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H1036	151	0	1	01	01	H1036_151_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		3.00		9.00																													0.00		0.00					3.00		9.00				3.00					3.00			3.00				
H1036	151	0	1	01	01	H1036_151_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1008.00	33																														33							33					33				33			33	2	3	
H1036	151	0	1	01	01	H1036_151_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		3.00		9.00																													0.00		0.00					3.00		9.00				3.00					3.00			3.00		2	3	1
H1036	151	0	1	01	01	H1036_151_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H1036	151	0	1	01	01	H1036_151_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H1036	151	0	1	01	01	H1036_151_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H1036	151	0	1	01	01	H1036_151_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					899.00	33																														33							33					33				33			33			
H1036	152	0	1	01	01	H1036_152_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1036	152	0	1	01	01	H1036_152_0	4	1	Preferred Generic	1	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	152	0	1	01	01	H1036_152_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					506.00	25																														25							25					25				25			25			
H1036	152	0	1	01	01	H1036_152_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1036	152	0	1	01	01	H1036_152_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	153	0	1	01	01	H1036_153_0	6	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H1036	153	0	1	01	01	H1036_153_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H1036	153	0	1	01	01	H1036_153_0	6	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H1036	153	0	1	01	01	H1036_153_0	6	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H1036	153	0	1	01	01	H1036_153_0	6	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					762.00	33																														33							33					33				33			33			
H1036	153	0	1	01	01	H1036_153_0	6	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					879.00	33																														33							33					33				33			33	2	3	
H1036	153	0	1	01	01	H1036_153_0	6	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H1036	153	0	1	01	01	H1036_153_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H1036	154	0	1	01	01	H1036_154_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					474.00	25																														25							25					25				25			25			
H1036	154	0	1	01	01	H1036_154_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	154	0	1	01	01	H1036_154_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	154	0	1	01	01	H1036_154_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1036	154	0	1	01	01	H1036_154_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1036	156	0	1	01	01	H1036_156_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					754.00	33																														33							33					33				33			33	2	1	
H1036	156	0	1	01	01	H1036_156_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H1036	156	0	1	01	01	H1036_156_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	3	
H1036	156	0	1	01	01	H1036_156_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	
H1036	156	0	1	01	01	H1036_156_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					738.00	33																														33							33					33				33			33			
H1036	156	0	1	01	01	H1036_156_0	6	1	Preferred Generic	3	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	3
H1036	156	0	1	01	01	H1036_156_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H1036	156	0	1	01	01	H1036_156_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H1036	156	0	1	01	01	H1036_156_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	156	0	1	01	01	H1036_156_0	6	1	Preferred Generic	1	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	157	0	1	01	01	H1036_157_0	3	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H1036	157	0	1	01	01	H1036_157_0	3	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H1036	157	0	1	01	01	H1036_157_0	3	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					737.00	33																														33							33					33				33			33	2	3	
H1036	157	0	1	01	01	H1036_157_0	3	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		3.00		9.00																													0.00		0.00					3.00		9.00				3.00					3.00			3.00				
H1036	157	0	1	01	01	H1036_157_0	3	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		9.00		27.00																													0.00		0.00					9.00		27.00				9.00					9.00			9.00				
H1036	157	0	1	01	01	H1036_157_0	3	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H1036	157	0	1	01	01	H1036_157_0	3	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		9.00		27.00																													0.00		0.00					9.00		27.00				9.00					9.00			9.00		2	2	
H1036	157	0	1	01	01	H1036_157_0	3	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		3.00		9.00																													0.00		0.00					3.00		9.00				3.00					3.00			3.00		2	3	1
H1036	157	0	1	01	01	H1036_157_0	3	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					622.00	33																														33							33					33				33			33			
H1036	157	0	1	01	01	H1036_157_0	3	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H1036	159	0	1	01	01	H1036_159_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1036	159	0	1	01	01	H1036_159_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1036	159	0	1	01	01	H1036_159_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	159	0	1	01	01	H1036_159_0	4	1	Preferred Generic	1	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	159	0	1	01	01	H1036_159_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					497.00	25																														25							25					25				25			25			
H1036	160	0	1	01	01	H1036_160_0	10	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		55.00		165.00																													55.00		155.00					55.00		165.00				55.00					55.00			55.00				
H1036	160	0	1	01	01	H1036_160_0	10	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					740.00	33																														33							33					33				33			33			
H1036	160	0	1	01	01	H1036_160_0	10	1	Preferred Generic	3	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1036	160	0	1	01	01	H1036_160_0	10	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1036	160	0	1	01	01	H1036_160_0	10	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	
H1036	160	0	1	01	01	H1036_160_0	10	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		55.00		165.00																													55.00		155.00					55.00		165.00				55.00					55.00			55.00		2	3	
H1036	160	0	1	01	01	H1036_160_0	10	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					749.00	33																														33							33					33				33			33	2	1	
H1036	160	0	1	01	01	H1036_160_0	10	1	Preferred Generic	1	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	160	0	1	01	01	H1036_160_0	10	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	160	0	1	01	01	H1036_160_0	10	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	161	0	1	01	01	H1036_161_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					474.00	25																														25							25					25				25			25			
H1036	161	0	1	01	01	H1036_161_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1036	161	0	1	01	01	H1036_161_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1036	161	0	1	01	01	H1036_161_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	161	0	1	01	01	H1036_161_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	162	0	1	01	01	H1036_162_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1036	162	0	1	01	01	H1036_162_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					495.00	25																														25							25					25				25			25			
H1036	162	0	1	01	01	H1036_162_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1036	162	0	1	01	01	H1036_162_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	162	0	1	01	01	H1036_162_0	4	1	Preferred Generic	1	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	163	0	1	01	01	H1036_163_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					539.00	25																														25							25					25				25			25			
H1036	163	0	1	01	01	H1036_163_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1036	163	0	1	01	01	H1036_163_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1036	163	0	1	01	01	H1036_163_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	163	0	1	01	01	H1036_163_0	4	1	Preferred Generic	1	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	164	0	1	01	01	H1036_164_0	4	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	3	
H1036	164	0	1	01	01	H1036_164_0	4	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					849.00	33																														33							33					33				33			33	2	1	
H1036	164	0	1	01	01	H1036_164_0	4	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		24.00		72.00																													24.00		62.00					24.00		72.00				24.00					24.00			24.00		2	3	
H1036	164	0	1	01	01	H1036_164_0	4	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	
H1036	164	0	1	01	01	H1036_164_0	4	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	1
H1036	164	0	1	01	01	H1036_164_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	164	0	1	01	01	H1036_164_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	164	0	1	01	01	H1036_164_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		24.00		72.00																													24.00		62.00					24.00		72.00				24.00					24.00			24.00				
H1036	164	0	1	01	01	H1036_164_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H1036	164	0	1	01	01	H1036_164_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					732.00	33																														33							33					33				33			33			
H1036	167	0	1	01	01	H1036_167_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					493.00	25																														25							25					25				25			25			
H1036	167	0	1	01	01	H1036_167_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		92.00		276.00																													92.00		266.00					92.00		276.00				92.00					92.00			92.00				
H1036	167	0	1	01	01	H1036_167_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		44.00		132.00																													44.00		122.00					44.00		132.00				44.00					44.00			44.00				
H1036	167	0	1	01	01	H1036_167_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	167	0	1	01	01	H1036_167_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	168	0	1	01	01	H1036_168_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		91.00		273.00																													91.00		263.00					91.00		273.00				91.00					91.00			91.00				
H1036	168	0	1	01	01	H1036_168_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					477.00	25																														25							25					25				25			25			
H1036	168	0	1	01	01	H1036_168_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		43.00		129.00																													43.00		119.00					43.00		129.00				43.00					43.00			43.00				
H1036	168	0	1	01	01	H1036_168_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	168	0	1	01	01	H1036_168_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	169	0	1	01	01	H1036_169_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	169	0	1	01	01	H1036_169_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	169	0	1	01	01	H1036_169_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		30.00		90.00																													30.00		80.00					30.00		90.00				30.00					30.00			30.00				
H1036	169	0	1	01	01	H1036_169_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		70.00		210.00																													70.00		200.00					70.00		210.00				70.00					70.00			70.00				
H1036	169	0	1	01	01	H1036_169_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					527.00	28																														28							28					28				28			28			
H1036	170	0	1	01	01	H1036_170_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		70.00		210.00																													70.00		200.00					70.00		210.00				70.00					70.00			70.00				
H1036	170	0	1	01	01	H1036_170_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		30.00		90.00																													30.00		80.00					30.00		90.00				30.00					30.00			30.00				
H1036	170	0	1	01	01	H1036_170_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	170	0	1	01	01	H1036_170_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	170	0	1	01	01	H1036_170_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					484.00	26																														26							26					26				26			26			
H1036	171	0	1	01	01	H1036_171_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H1036	171	0	1	01	01	H1036_171_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H1036	171	0	1	01	01	H1036_171_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H1036	171	0	1	01	01	H1036_171_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H1036	171	0	1	01	01	H1036_171_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					706.00	30																														30							30					30				30			30			
H1036	171	0	1	01	01	H1036_171_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1036	171	0	1	01	01	H1036_171_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					809.00	30																														30							30					30				30			30	2	3	
H1036	171	0	1	01	01	H1036_171_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H1036	171	0	1	01	01	H1036_171_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H1036	171	0	1	01	01	H1036_171_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1036	175	0	1	01	01	H1036_175_0	4	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00		2	3	
H1036	175	0	1	01	01	H1036_175_0	4	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					780.00	33																														33							33					33				33			33	2	1	
H1036	175	0	1	01	01	H1036_175_0	4	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	3	
H1036	175	0	1	01	01	H1036_175_0	4	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00		2	3	
H1036	175	0	1	01	01	H1036_175_0	4	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	1
H1036	175	0	1	01	01	H1036_175_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					754.00	33																														33							33					33				33			33			
H1036	175	0	1	01	01	H1036_175_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00				
H1036	175	0	1	01	01	H1036_175_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1036	175	0	1	01	01	H1036_175_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00				
H1036	175	0	1	01	01	H1036_175_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	178	0	1	01	01	H1036_178_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H1036	178	0	1	01	01	H1036_178_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H1036	178	0	1	01	01	H1036_178_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					761.00	33																														33							33					33				33			33	2	3	
H1036	178	0	1	01	01	H1036_178_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H1036	178	0	1	01	01	H1036_178_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H1036	178	0	1	01	01	H1036_178_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H1036	178	0	1	01	01	H1036_178_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H1036	178	0	1	01	01	H1036_178_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					738.00	33																														33							33					33				33			33			
H1036	178	0	1	01	01	H1036_178_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1036	178	0	1	01	01	H1036_178_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1036	179	0	1	01	01	H1036_179_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					748.00	33																														33							33					33				33			33	2	3	
H1036	179	0	1	01	01	H1036_179_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H1036	179	0	1	01	01	H1036_179_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1036	179	0	1	01	01	H1036_179_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1036	179	0	1	01	01	H1036_179_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		3.00		9.00																													0.00		0.00					3.00		9.00				3.00					3.00			3.00				
H1036	179	0	1	01	01	H1036_179_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		3.00		9.00																													0.00		0.00					3.00		9.00				3.00					3.00			3.00		2	3	1
H1036	179	0	1	01	01	H1036_179_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H1036	179	0	1	01	01	H1036_179_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H1036	179	0	1	01	01	H1036_179_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H1036	179	0	1	01	01	H1036_179_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					730.00	33																														33							33					33				33			33			
H1036	184	0	1	01	01	H1036_184_0	4	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H1036	184	0	1	01	01	H1036_184_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					744.00	33																														33							33					33				33			33			
H1036	184	0	1	01	01	H1036_184_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H1036	184	0	1	01	01	H1036_184_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H1036	184	0	1	01	01	H1036_184_0	4	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					875.00	33																														33							33					33				33			33	2	3	
H1036	184	0	1	01	01	H1036_184_0	4	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H1036	184	0	1	01	01	H1036_184_0	4	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	3	
H1036	184	0	1	01	01	H1036_184_0	4	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H1036	184	0	1	01	01	H1036_184_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1036	184	0	1	01	01	H1036_184_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H1036	185	0	1	01	01	H1036_185_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1036	185	0	1	01	01	H1036_185_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	185	0	1	01	01	H1036_185_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	185	0	1	01	01	H1036_185_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					495.00	25																														25							25					25				25			25			
H1036	185	0	1	01	01	H1036_185_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1036	186	0	1	01	01	H1036_186_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	186	0	1	01	01	H1036_186_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1036	186	0	1	01	01	H1036_186_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													10.00		20.00					10.00		30.00				10.00					10.00			10.00				
H1036	186	0	1	01	01	H1036_186_0	4	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													10.00		20.00					10.00		30.00				10.00					10.00			10.00		2	3	
H1036	186	0	1	01	01	H1036_186_0	4	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	3	
H1036	186	0	1	01	01	H1036_186_0	4	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1036	186	0	1	01	01	H1036_186_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					687.00	33																														33							33					33				33			33			
H1036	186	0	1	01	01	H1036_186_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	186	0	1	01	01	H1036_186_0	4	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					821.00	33																														33							33					33				33			33	2	1	
H1036	186	0	1	01	01	H1036_186_0	4	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1036	187	0	1	01	01	H1036_187_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					539.00	25																														25							25					25				25			25			
H1036	187	0	1	01	01	H1036_187_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1036	187	0	1	01	01	H1036_187_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1036	187	0	1	01	01	H1036_187_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	187	0	1	01	01	H1036_187_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	188	0	1	01	01	H1036_188_0	4	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					845.00	33																														33							33					33				33			33	2	1	
H1036	188	0	1	01	01	H1036_188_0	4	1	Preferred Generic	3	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1036	188	0	1	01	01	H1036_188_0	4	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	
H1036	188	0	1	01	01	H1036_188_0	4	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1036	188	0	1	01	01	H1036_188_0	4	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		25.00		75.00																													25.00		65.00					25.00		75.00				25.00					25.00			25.00		2	3	
H1036	188	0	1	01	01	H1036_188_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					551.00	33																														33							33					33				33			33			
H1036	188	0	1	01	01	H1036_188_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		25.00		75.00																													25.00		65.00					25.00		75.00				25.00					25.00			25.00				
H1036	188	0	1	01	01	H1036_188_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	188	0	1	01	01	H1036_188_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	188	0	1	01	01	H1036_188_0	4	1	Preferred Generic	1	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	189	0	1	01	01	H1036_189_0	4	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1036	189	0	1	01	01	H1036_189_0	4	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	
H1036	189	0	1	01	01	H1036_189_0	4	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		25.00		75.00																													25.00		65.00					25.00		75.00				25.00					25.00			25.00		2	3	
H1036	189	0	1	01	01	H1036_189_0	4	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1097.00	33																														33							33					33				33			33	2	1	
H1036	189	0	1	01	01	H1036_189_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	189	0	1	01	01	H1036_189_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					596.00	33																														33							33					33				33			33			
H1036	189	0	1	01	01	H1036_189_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		25.00		75.00																													25.00		65.00					25.00		75.00				25.00					25.00			25.00				
H1036	189	0	1	01	01	H1036_189_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	189	0	1	01	01	H1036_189_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	189	0	1	01	01	H1036_189_0	4	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1036	190	0	1	01	01	H1036_190_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	190	0	1	01	01	H1036_190_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	190	0	1	01	01	H1036_190_0	4	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					836.00	33																														33							33					33				33			33	2	1	
H1036	190	0	1	01	01	H1036_190_0	4	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H1036	190	0	1	01	01	H1036_190_0	4	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		35.00		105.00																													35.00		95.00					35.00		105.00				35.00					35.00			35.00		2	3	
H1036	190	0	1	01	01	H1036_190_0	4	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1036	190	0	1	01	01	H1036_190_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		35.00		105.00																													35.00		95.00					35.00		105.00				35.00					35.00			35.00				
H1036	190	0	1	01	01	H1036_190_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H1036	190	0	1	01	01	H1036_190_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					700.00	33																														33							33					33				33			33			
H1036	190	0	1	01	01	H1036_190_0	4	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1036	192	0	1	01	01	H1036_192_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	192	0	1	01	01	H1036_192_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1036	192	0	1	01	01	H1036_192_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1036	192	0	1	01	01	H1036_192_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					475.00	25																														25							25					25				25			25			
H1036	192	0	1	01	01	H1036_192_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	193	0	1	01	01	H1036_193_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H1036	193	0	1	01	01	H1036_193_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					788.00	33																														33							33					33				33			33	2	1	
H1036	193	0	1	01	01	H1036_193_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		20.00		60.00																													20.00		50.00					20.00		60.00				20.00					20.00			20.00		2	3	
H1036	193	0	1	01	01	H1036_193_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1036	193	0	1	01	01	H1036_193_0	5	1	Preferred Generic	3	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H1036	193	0	1	01	01	H1036_193_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					775.00	33																														33							33					33				33			33			
H1036	193	0	1	01	01	H1036_193_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H1036	193	0	1	01	01	H1036_193_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		20.00		60.00																													20.00		50.00					20.00		60.00				20.00					20.00			20.00				
H1036	193	0	1	01	01	H1036_193_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	193	0	1	01	01	H1036_193_0	5	1	Preferred Generic	1	4	001010	3	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	194	0	1	01	01	H1036_194_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	194	0	1	01	01	H1036_194_0	4	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	
H1036	194	0	1	01	01	H1036_194_0	4	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	3	
H1036	194	0	1	01	01	H1036_194_0	4	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H1036	194	0	1	01	01	H1036_194_0	4	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					786.00	33																														33							33					33				33			33	2	1	
H1036	194	0	1	01	01	H1036_194_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H1036	194	0	1	01	01	H1036_194_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					760.00	33																														33							33					33				33			33			
H1036	194	0	1	01	01	H1036_194_0	4	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	3
H1036	194	0	1	01	01	H1036_194_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	194	0	1	01	01	H1036_194_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H1036	195	0	1	01	01	H1036_195_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	195	0	1	01	01	H1036_195_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1036	195	0	1	01	01	H1036_195_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1036	195	0	1	01	01	H1036_195_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					485.00	25																														25							25					25				25			25			
H1036	195	0	1	01	01	H1036_195_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	196	0	1	01	01	H1036_196_0	3	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					686.00	33																														33							33					33				33			33			
H1036	196	0	1	01	01	H1036_196_0	3	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		75.00		225.00																													75.00		215.00					75.00		225.00				75.00					75.00			75.00				
H1036	196	0	1	01	01	H1036_196_0	3	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H1036	196	0	1	01	01	H1036_196_0	3	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H1036	196	0	1	01	01	H1036_196_0	3	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	1
H1036	196	0	1	01	01	H1036_196_0	3	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H1036	196	0	1	01	01	H1036_196_0	3	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1036	196	0	1	01	01	H1036_196_0	3	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		75.00		225.00																													75.00		215.00					75.00		225.00				75.00					75.00			75.00		2	3	
H1036	196	0	1	01	01	H1036_196_0	3	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					797.00	33																														33							33					33				33			33	2	1	
H1036	196	0	1	01	01	H1036_196_0	3	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H1036	199	0	1	01	01	H1036_199_0	3	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H1036	199	0	1	01	01	H1036_199_0	3	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1036	199	0	1	01	01	H1036_199_0	3	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1036	199	0	1	01	01	H1036_199_0	3	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					698.00	33																														33							33					33				33			33			
H1036	199	0	1	01	01	H1036_199_0	3	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00		2	3	1
H1036	199	0	1	01	01	H1036_199_0	3	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H1036	199	0	1	01	01	H1036_199_0	3	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H1036	199	0	1	01	01	H1036_199_0	3	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H1036	199	0	1	01	01	H1036_199_0	3	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					813.00	33																														33							33					33				33			33	2	3	
H1036	199	0	1	01	01	H1036_199_0	3	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00				
H1045	001	0	1	02	01	H1045_001_0	4	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14					816.51	33	33	33																					33	33	33																	33				33			33			
H1045	001	0	1	02	01	H1045_001_0	4	3	Non-Preferred Brand	1	4	110000	1	2	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14		20.00	40.00	60.00																						20.00	40.00	40.00																		20.00					20.00			20.00				
H1045	001	0	1	02	01	H1045_001_0	4	2	Preferred Brand	1	4	010001	3	2	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14		0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00			0.00				
H1045	001	0	1	02	01	H1045_001_0	4	1	Generic	3	4	010010	3	2	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14		0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00			0.00		1		
H1045	001	0	1	02	01	H1045_001_0	4	1	Generic	1	4	010010	3	2	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14		0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00			0.00				
H1045	005	0	1	01	01	H1045_005_0	4	1	Generic	3	4	010010	3	2	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14		0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00			0.00		1		
H1045	005	0	1	01	01	H1045_005_0	4	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14					1245.77	33	33	33																					33	33	33																	33				33			33			
H1045	005	0	1	01	01	H1045_005_0	4	2	Preferred Brand	1	4	010001	3	2	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14		15.00	30.00	45.00																						15.00	30.00	30.00																		15.00					15.00			15.00				
H1045	005	0	1	01	01	H1045_005_0	4	3	Non-Preferred Brand	1	4	110000	1	2	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14		30.00	60.00	90.00																						30.00	60.00	60.00																		30.00					30.00			30.00				
H1045	005	0	1	01	01	H1045_005_0	4	1	Generic	1	4	010010	3	2	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14		0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00			0.00				
H1045	012	0	1	02	01	H1045_012_0	3	2	Preferred Brand	3	4	010001	3	2	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14		0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00			0.00		1		
H1045	012	0	1	02	01	H1045_012_0	3	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14					362.79	25	25	25																					25	25	25																	25				25			25			
H1045	012	0	1	02	01	H1045_012_0	3	3	Non-Preferred Brand	1	4	110000	1	2	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14		0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00			0.00				
H1045	012	0	1	02	01	H1045_012_0	3	2	Preferred Brand	1	4	010001	3	2	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14		0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00			0.00				
H1045	012	0	1	02	01	H1045_012_0	3	1	Generic	1	4	010010	3	2	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14		0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00			0.00				
H1045	012	0	1	02	01	H1045_012_0	3	1	Generic	3	4	010010	3	2	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14		0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00			0.00		1		
H1045	016	0	1	01	01	H1045_016_0	3	2	Preferred Brand	3	4	010001	3	2	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14		0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00			0.00		1		
H1045	016	0	1	01	01	H1045_016_0	3	1	Generic	3	4	010010	3	2	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14		0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00			0.00		1		
H1045	016	0	1	01	01	H1045_016_0	3	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14					577.93	33	33	33																					33	33	33																	33				33			33			
H1045	016	0	1	01	01	H1045_016_0	3	3	Non-Preferred Brand	1	4	110000	1	2	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14		20.00	40.00	60.00																						20.00	40.00	40.00																		20.00					20.00			20.00				
H1045	016	0	1	01	01	H1045_016_0	3	2	Preferred Brand	1	4	010001	3	2	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14		0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00			0.00				
H1045	016	0	1	01	01	H1045_016_0	3	1	Generic	1	4	010010	3	2	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14		0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00			0.00				
H1045	018	0	1	01	01	H1045_018_0	3	2	Preferred Brand	3	4	010001	3	2	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14		0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00			0.00		1		
H1045	018	0	1	01	01	H1045_018_0	3	1	Generic	3	4	010010	3	2	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14		0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00			0.00		1		
H1045	018	0	1	01	01	H1045_018_0	3	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14					577.93	33	33	33																					33	33	33																	33				33			33			
H1045	018	0	1	01	01	H1045_018_0	3	2	Preferred Brand	1	4	010001	3	2	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14		0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00			0.00				
H1045	018	0	1	01	01	H1045_018_0	3	3	Non-Preferred Brand	1	4	110000	1	2	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14		20.00	40.00	60.00																						20.00	40.00	40.00																		20.00					20.00			20.00				
H1045	018	0	1	01	01	H1045_018_0	3	1	Generic	1	4	010010	3	2	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14		0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00			0.00				
H1045	020	0	1	01	01	H1045_020_0	3	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14					2722.26	33	33	33																					33	33	33																	33				33			33			
H1045	020	0	1	01	01	H1045_020_0	3	3	Non-Preferred Brand	1	4	110000	1	2	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14		50.00	100.00	150.00																						50.00	100.00	100.00																		50.00					50.00			50.00				
H1045	020	0	1	01	01	H1045_020_0	3	2	Preferred Brand	1	4	010001	3	2	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14		10.00	20.00	30.00																						10.00	20.00	20.00																		10.00					10.00			10.00				
H1045	020	0	1	01	01	H1045_020_0	3	1	Generic	3	4	010010	3	2	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14		0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00			0.00		1		
H1045	020	0	1	01	01	H1045_020_0	3	1	Generic	1	4	010010	3	2	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14		0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00			0.00				
H1045	022	0	1	01	01	H1045_022_0	3	1	Generic	3	4	010010	3	2	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14		0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00			0.00		1		
H1045	022	0	1	01	01	H1045_022_0	3	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14					1033.89	33	33	33																					33	33	33																	33				33			33			
H1045	022	0	1	01	01	H1045_022_0	3	2	Preferred Brand	1	4	010001	3	2	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14		20.00	40.00	60.00																						20.00	40.00	40.00																		20.00					20.00			20.00				
H1045	022	0	1	01	01	H1045_022_0	3	3	Non-Preferred Brand	1	4	110000	1	2	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14		60.00	120.00	180.00																						60.00	120.00	120.00																		60.00					60.00			60.00				
H1045	022	0	1	01	01	H1045_022_0	3	1	Generic	1	4	010010	3	2	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14		0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00			0.00				
H1045	023	0	1	01	01	H1045_023_0	4	3	Non-Preferred Brand	1	4	110000	1	2	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14		95.00	190.00	285.00																						95.00	190.00	275.00																		95.00					95.00			95.00				
H1045	023	0	1	01	01	H1045_023_0	4	2	Preferred Brand	1	4	010001	3	2	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14		40.00	80.00	120.00																						40.00	80.00	110.00																		40.00					40.00			40.00				
H1045	023	0	1	01	01	H1045_023_0	4	1	Generic	1	4	010010	3	2	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14		0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00			0.00				
H1045	023	0	1	01	01	H1045_023_0	4	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14					712.13	33	33	33																					33	33	33																	33				33			33			
H1045	023	0	1	01	01	H1045_023_0	4	1	Generic	3	4	010010	3	2	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14		0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00			0.00		1		
H1076	003	0	1	01	01	H1076_003_0	10	1	Preferred Generic	3	4	001010	3	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00		1		
H1076	003	0	1	01	01	H1076_003_0	10	1	Preferred Generic	1	4	001010	3	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00				
H1076	003	0	1	01	01	H1076_003_0	10	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		20.00		40.00																						20.00		40.00																		20.00								20.00				
H1076	003	0	1	01	01	H1076_003_0	10	3	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		50.00		150.00																						50.00		150.00																		50.00					50.00			50.00				
H1076	003	0	1	01	01	H1076_003_0	10	4	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					552.88	33																																										33				33			33			
H1076	011	0	1	01	01	H1076_011_0	10	1	Preferred Generic	1	4	001010	3	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00				
H1076	011	0	1	01	01	H1076_011_0	10	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		45.00		90.00																						45.00		90.00																		45.00								45.00				
H1076	011	0	1	01	01	H1076_011_0	10	3	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		76.00		228.00																						76.00		228.00																		76.00					76.00			76.00				
H1076	011	0	1	01	01	H1076_011_0	10	4	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					580.39	33																																										33				33			33			
H1080	004	0	1	02	01	H1080_004_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					529.00	33		33																														33							33			33				33			33			
H1080	004	0	1	02	01	H1080_004_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H1080	004	0	1	02	01	H1080_004_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H1080	004	0	1	02	01	H1080_004_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H1080	004	0	1	02	01	H1080_004_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00							
H1080	042	0	1	01	01	H1080_042_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H1080	042	0	1	01	01	H1080_042_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					924.00	33		33																														33							33			33				33			33			
H1080	042	0	1	01	01	H1080_042_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H1080	042	0	1	01	01	H1080_042_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H1080	042	0	1	01	01	H1080_042_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00							
H1080	043	0	1	01	01	H1080_043_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					476.00	33		33																														33							33			33				33			33			
H1080	043	0	1	01	01	H1080_043_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H1080	043	0	1	01	01	H1080_043_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H1080	043	0	1	01	01	H1080_043_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H1080	043	0	1	01	01	H1080_043_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00							
H1080	044	0	1	01	01	H1080_044_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					5.00		15.00																															10.00							15.00				5.00					5.00							
H1080	044	0	1	01	01	H1080_044_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00							
H1080	044	0	1	01	01	H1080_044_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H1080	044	0	1	01	01	H1080_044_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H1080	044	0	1	01	01	H1080_044_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					475.00	33		33																														33							33			33				33			33			
H1080	045	0	1	01	01	H1080_045_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					529.00	33		33																														33							33			33				33			33			
H1080	045	0	1	01	01	H1080_045_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H1080	045	0	1	01	01	H1080_045_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H1080	045	0	1	01	01	H1080_045_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H1080	045	0	1	01	01	H1080_045_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00							
H1099	001	0	1	02	01	H1099_001_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					2.00		6.00																								6.00																		2.00					2.00							
H1099	001	0	1	02	01	H1099_001_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							2			90							30		31					10.00		30.00																								20.00																		10.00					10.00							
H1099	001	0	1	02	01	H1099_001_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		45.00		135.00																								112.50																		45.00								45.00				
H1099	001	0	1	02	01	H1099_001_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							2			90							30				31	14		90.00		270.00																								225.00																		90.00								90.00				
H1099	001	0	1	02	01	H1099_001_0	9	5	Specialty Tier	1	4	000010	1	1	110100000010001000000001	30		90							2			90							30				31	14					581.28	33		33																							33																	33							33			
H1099	001	0	1	02	01	H1099_001_0	9	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					2.00		6.00																								6.00																		2.00					2.00					1		
H1099	001	0	1	02	01	H1099_001_0	9	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							2			90							30		31					10.00		30.00																								20.00																		10.00					10.00					1		
H1099	006	0	1	01	01	H1099_006_0	9	5	Specialty Tier	1	4	000010	1	1	110100000010001000000001	30		90							2			90							30				31	14					602.84	33		33																							33																	33							33			
H1099	006	0	1	01	01	H1099_006_0	9	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					2.00		6.00																								6.00																		2.00					2.00					1		
H1099	006	0	1	01	01	H1099_006_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							2			90							30				31	14		90.00		270.00																								225.00																		90.00								90.00				
H1099	006	0	1	01	01	H1099_006_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		45.00		135.00																								112.50																		45.00								45.00				
H1099	006	0	1	01	01	H1099_006_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							2			90							30		31					10.00		30.00																								20.00																		10.00					10.00							
H1099	006	0	1	01	01	H1099_006_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					2.00		6.00																								6.00																		2.00					2.00							
H1099	014	0	1	01	01	H1099_014_0	11	5	Specialty Tier	1	4	000010	1	1	110100000010001000000001	30		90							2			90							30				31	14					843.35	33		33																							33																	33							33			
H1099	014	0	1	01	01	H1099_014_0	11	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							2			90							30				31	14		95.00		285.00																								237.50																		95.00								95.00				
H1099	014	0	1	01	01	H1099_014_0	11	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		45.00		135.00																								112.50																		45.00								45.00				
H1099	014	0	1	01	01	H1099_014_0	11	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							2			90							30		31					10.00		30.00																								20.00																		10.00					10.00							
H1099	014	0	1	01	01	H1099_014_0	11	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					2.00		6.00																								6.00																		2.00					2.00							
H1099	015	0	1	01	01	H1099_015_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					2.00		6.00																								6.00																		2.00					2.00							
H1099	015	0	1	01	01	H1099_015_0	10	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					2.00		6.00																								6.00																		2.00					2.00					1		
H1099	015	0	1	01	01	H1099_015_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							2			90							30		31					10.00		30.00																								20.00																		10.00					10.00							
H1099	015	0	1	01	01	H1099_015_0	10	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		45.00		135.00																								112.50																		45.00								45.00				
H1099	015	0	1	01	01	H1099_015_0	10	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							2			90							30				31	14		90.00		270.00																								225.00																		90.00								90.00				
H1099	015	0	1	01	01	H1099_015_0	10	5	Specialty Tier	1	4	000010	1	1	110100000010001000000001	30		90							2			90							30				31	14					581.28	33		33																							33																	33							33			
H1099	015	0	1	01	01	H1099_015_0	10	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							2			90							30		31					10.00		30.00																								20.00																		10.00					10.00					1		
H1109	001	0	1	01	01	H1109_001_0	6	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					7.00	14.00	21.00																													7.00	14.00	14.00					7.00	14.00	21.00					7.00				7.00							
H1109	001	0	1	01	01	H1109_001_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H1109	001	0	1	01	01	H1109_001_0	6	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H1109	001	0	1	01	01	H1109_001_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H1109	001	0	1	01	01	H1109_001_0	6	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					436.45	33	33	33																												33	33	33					33	33	33				33			33			33			
H1110	001	0	1	04	01	H1110_001_0	8	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					7.00	14.00	21.00																													7.00	14.00	14.00					7.00	14.00	21.00					7.00				7.00							
H1110	001	0	1	04	01	H1110_001_0	8	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H1110	001	0	1	04	01	H1110_001_0	8	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H1110	001	0	1	04	01	H1110_001_0	8	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					224.14	33	33	33																												33	33	33					33	33	33				33			33			33			
H1110	001	0	1	04	01	H1110_001_0	8	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H1111	002	0	1	01	01	H1111_002_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H1111	002	0	1	01	01	H1111_002_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					542.00	33		33																														33							33			33				33			33			
H1111	002	0	1	01	01	H1111_002_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H1111	002	0	1	01	01	H1111_002_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H1111	002	0	1	01	01	H1111_002_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H1111	006	0	1	01	01	H1111_006_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		42.00		126.00																															116.00							126.00				42.00					42.00			42.00				
H1111	006	0	1	01	01	H1111_006_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H1111	006	0	1	01	01	H1111_006_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					488.00	33		33																														33							33			33				33			33			
H1111	006	0	1	01	01	H1111_006_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					5.00		15.00																															10.00							15.00				5.00					5.00							
H1111	006	0	1	01	01	H1111_006_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H1112	006	0	1	01	01	H1112_006_0	6	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	31													31			31			31		31		31	14					707.00	25																														25							25					25				25			25			
H1112	006	0	1	01	01	H1112_006_0	6	3	Non-Preferred Brand	1	4	110000	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		95.00	190.00	285.00																													95.00	190.00	190.00							285.00				95.00					95.00			95.00				
H1112	006	0	1	01	01	H1112_006_0	6	1	Preferred Generic	1	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
H1112	006	0	1	01	01	H1112_006_0	6	2	Preferred Brand	1	4	010001	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		45.00	90.00	135.00																													45.00	90.00	90.00							135.00				45.00					45.00			45.00				
H1112	027	0	1	02	01	H1112_027_0	7	3	Non-Preferred Brand	1	4	100000	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		75.00	150.00	225.00																													75.00	150.00	150.00							225.00				75.00								75.00				
H1112	027	0	1	02	01	H1112_027_0	7	2	Preferred Brand	1	4	000001	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		39.00	78.00	117.00																													39.00	78.00	78.00							117.00				39.00								39.00				
H1112	027	0	1	02	01	H1112_027_0	7	1	Generic	1	4	010010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		3.00	6.00	9.00																													3.00	6.00	0.00							9.00				3.00					3.00			3.00				
H1112	027	0	1	02	01	H1112_027_0	7	4	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
H1170	002	0	1	01	01	H1170_002_0	8	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													5.00		15.00						10.00		30.00						5.00		10.00																		10.00					10.00							
H1170	002	0	1	01	01	H1170_002_0	8	6	Vaccines	3	4	000001	1	2	100010010010000000000000				30			30													30					1										0.00								0.00																												0.00										1		
H1170	002	0	1	01	01	H1170_002_0	8	2	Non-Preferred Generic	3	4	000100	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													10.00		30.00						20.00		60.00						10.00		20.00																		20.00					20.00					1		
H1170	002	0	1	01	01	H1170_002_0	8	1	Preferred Generic	3	4	001000	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													5.00		15.00						10.00		30.00						5.00		10.00																		10.00					10.00					1		
H1170	002	0	1	01	01	H1170_002_0	8	6	Vaccines	1	4	000001	1	2	100010010010000000000000				30			30													30					1										0.00								0.00																												0.00												
H1170	002	0	1	01	01	H1170_002_0	8	5	Specialty Tier	1	4	100001	1	1	100010110110101000000001				30		90	30		90	2	30		90							30				31	14													551.00	25		25					551.00	25		25					25		25																	25							25			
H1170	002	0	1	01	01	H1170_002_0	8	4	Non-Preferred Brand	1	4	100000	1	2	100010110110101000000001				30		90	30		90	2	30		90							30				31	14										75.00		225.00						85.00		255.00						75.00		150.00																		85.00								85.00				
H1170	002	0	1	01	01	H1170_002_0	8	3	Preferred Brand	1	4	000001	1	2	100010110110101000000001				30		90	30		90	2	30		90							30				31	14										44.00		132.00						45.00		135.00						44.00		88.00																		45.00								45.00				
H1170	002	0	1	01	01	H1170_002_0	8	2	Non-Preferred Generic	1	4	000100	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													10.00		30.00						20.00		60.00						10.00		20.00																		20.00					20.00							
H1170	008	0	1	01	01	H1170_008_0	8	3	Preferred Brand	1	3	000001		2	100010110110101000000001				30		90	30		90	2	30		90							30				31	14										44.00		132.00						45.00		135.00						44.00		88.00																		45.00								45.00				
H1170	008	0	1	01	01	H1170_008_0	8	6	Vaccines	1	3	000001		2	100010010010000000000000				30			30													30					1										0.00								0.00																												0.00												
H1170	008	0	1	01	01	H1170_008_0	8	2	Non-Preferred Generic	1	3	000100		2	000010110110101000000100				30		90	30		90	2	30		90							30		31													15.00		45.00						30.00		90.00						15.00		30.00																		30.00					30.00							
H1170	008	0	1	01	01	H1170_008_0	8	1	Preferred Generic	1	3	001000		2	000010110110101000000100				30		90	30		90	2	30		90							30		31													5.00		15.00						10.00		30.00						5.00		10.00																		10.00					10.00							
H1170	008	0	1	01	01	H1170_008_0	8	5	Specialty Tier	1	3	100001		1	100010110110101000000001				30		90	30		90	2	30		90							30				31	14													533.00	25		25					533.00	25		25					25		25																	25							25			
H1170	008	0	1	01	01	H1170_008_0	8	4	Non-Preferred Brand	1	3	100000		2	100010110110101000000001				30		90	30		90	2	30		90							30				31	14										75.00		225.00						85.00		255.00						75.00		150.00																		85.00								85.00				
H1170	009	0	1	01	01	H1170_009_0	8	6	Vaccines	1	4	000001	1	2	100010010010000000000000				30			30													30					1										0.00								0.00																												0.00												
H1170	009	0	1	01	01	H1170_009_0	8	1	Preferred Generic	3	4	001000	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													7.00		21.00						10.00		30.00						7.00		14.00																		10.00					10.00					1		
H1170	009	0	1	01	01	H1170_009_0	8	5	Specialty Tier	1	4	100001	1	1	100010110110101000000001				30		90	30		90	2	30		90							30				31	14													567.00	25		25					567.00	25		25					25		25																	25							25			
H1170	009	0	1	01	01	H1170_009_0	8	4	Non-Preferred Brand	1	4	100000	1	2	100010110110101000000001				30		90	30		90	2	30		90							30				31	14										75.00		225.00						85.00		255.00						75.00		150.00																		85.00								85.00				
H1170	009	0	1	01	01	H1170_009_0	8	3	Preferred Brand	1	4	000001	1	2	100010110110101000000001				30		90	30		90	2	30		90							30				31	14										44.00		132.00						45.00		135.00						44.00		88.00																		45.00								45.00				
H1170	009	0	1	01	01	H1170_009_0	8	2	Non-Preferred Generic	1	4	000100	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													10.00		30.00						20.00		60.00						10.00		20.00																		20.00					20.00							
H1170	009	0	1	01	01	H1170_009_0	8	2	Non-Preferred Generic	3	4	000100	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													10.00		30.00						20.00		60.00						10.00		20.00																		20.00					20.00					1		
H1170	009	0	1	01	01	H1170_009_0	8	6	Vaccines	3	4	000001	1	2	100010010010000000000000				30			30													30					1										0.00								0.00																												0.00										1		
H1170	009	0	1	01	01	H1170_009_0	8	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													7.00		21.00						10.00		30.00						7.00		14.00																		10.00					10.00							
H1216	001	0	1	02	01	H1216_001_0	7	2	Preferred Brand	1	4	000001	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		29.00	58.00	87.00																													29.00	58.00	58.00							87.00				29.00								29.00				
H1216	001	0	1	02	01	H1216_001_0	7	3	Non-Preferred Brand	1	4	100000	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		69.00	138.00	207.00																													69.00	138.00	138.00							207.00				69.00								69.00				
H1216	001	0	1	02	01	H1216_001_0	7	4	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
H1216	001	0	1	02	01	H1216_001_0	7	1	Generic	1	4	010010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		3.00	6.00	9.00																													3.00	6.00	0.00							9.00				3.00					3.00			3.00				
H1216	003	0	1	01	01	H1216_003_0	7	1	Preferred Generic	1	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
H1216	003	0	1	01	01	H1216_003_0	7	2	Preferred Brand	1	4	010001	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		42.00	84.00	126.00																													42.00	84.00	84.00							126.00				42.00					42.00			42.00				
H1216	003	0	1	01	01	H1216_003_0	7	3	Non-Preferred Brand	1	4	110000	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		94.00	188.00	282.00																													94.00	188.00	188.00							282.00				94.00					94.00			94.00				
H1216	003	0	1	01	01	H1216_003_0	7	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	31													31			31			31		31		31	14					707.00	25																														25							25					25				25			25			
H1230	001	0	1	01	01	H1230_001_0	8	6	Vaccines	3	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00										1		
H1230	001	0	1	01	01	H1230_001_0	8	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00					1		
H1230	001	0	1	01	01	H1230_001_0	8	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					6.00		18.00																						6.00		12.00																		6.00					6.00					1		
H1230	001	0	1	01	01	H1230_001_0	8	6	Vaccines	1	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00												
H1230	001	0	1	01	01	H1230_001_0	8	5	Specialty Tier	1	4	100001	1	1	110100000010101000000001	30		90							2	30		90							30				31	14					632.00	25		25																					25		25																	25							25			
H1230	001	0	1	01	01	H1230_001_0	8	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		75.00		225.00																						75.00		150.00																		75.00								75.00				
H1230	001	0	1	01	01	H1230_001_0	8	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		45.00		135.00																						45.00		90.00																		45.00								45.00				
H1230	001	0	1	01	01	H1230_001_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					6.00		18.00																						6.00		12.00																		6.00					6.00							
H1230	001	0	1	01	01	H1230_001_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00							
H1230	003	0	1	01	01	H1230_003_0	6	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					6.00		18.00																						6.00		12.00																		6.00					6.00					1		
H1230	003	0	1	01	01	H1230_003_0	6	6	Vaccines	3	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00										1		
H1230	003	0	1	01	01	H1230_003_0	6	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00					1		
H1230	003	0	1	01	01	H1230_003_0	6	6	Vaccines	1	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00												
H1230	003	0	1	01	01	H1230_003_0	6	5	Specialty Tier	1	4	100001	1	1	110100000010101000000001	30		90							2	30		90							30				31	14					690.00	25		25																					25		25																	25							25			
H1230	003	0	1	01	01	H1230_003_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		75.00		225.00																						75.00		150.00																		75.00								75.00				
H1230	003	0	1	01	01	H1230_003_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		45.00		135.00																						45.00		90.00																		45.00								45.00				
H1230	003	0	1	01	01	H1230_003_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00							
H1230	003	0	1	01	01	H1230_003_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					6.00		18.00																						6.00		12.00																		6.00					6.00							
H1230	005	0	1	01	01	H1230_005_0	5	5	Specialty Tier	1	4	100001	1	1	110100000010101000000001	30		90							2	30		90							30				31	14					511.00	25		25																					25		25																	25							25			
H1230	005	0	1	01	01	H1230_005_0	5	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00					1		
H1230	005	0	1	01	01	H1230_005_0	5	6	Vaccines	3	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00										1		
H1230	005	0	1	01	01	H1230_005_0	5	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					7.00		21.00																						7.00		14.00																		7.00					7.00							
H1230	005	0	1	01	01	H1230_005_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00							
H1230	005	0	1	01	01	H1230_005_0	5	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		45.00		135.00																						45.00		90.00																		45.00								45.00				
H1230	005	0	1	01	01	H1230_005_0	5	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		75.00		225.00																						75.00		150.00																		75.00								75.00				
H1230	005	0	1	01	01	H1230_005_0	5	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					7.00		21.00																						7.00		14.00																		7.00					7.00					1		
H1230	005	0	1	01	01	H1230_005_0	5	6	Vaccines	1	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00												
H1230	006	0	1	01	01	H1230_006_0	7	6	Vaccines	1	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00												
H1230	006	0	1	01	01	H1230_006_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					6.00		18.00																						6.00		12.00																		6.00					6.00							
H1230	006	0	1	01	01	H1230_006_0	7	5	Specialty Tier	1	4	100001	1	1	110100000010101000000001	30		90							2	30		90							30				31	14					491.00	25		25																					25		25																	25							25			
H1230	006	0	1	01	01	H1230_006_0	7	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00					1		
H1230	006	0	1	01	01	H1230_006_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		75.00		225.00																						75.00		150.00																		75.00								75.00				
H1230	006	0	1	01	01	H1230_006_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00							
H1230	006	0	1	01	01	H1230_006_0	7	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					6.00		18.00																						6.00		12.00																		6.00					6.00					1		
H1230	006	0	1	01	01	H1230_006_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		45.00		135.00																						45.00		90.00																		45.00								45.00				
H1230	006	0	1	01	01	H1230_006_0	7	6	Vaccines	3	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00										1		
H1251	003	0	1	18	06	H1251_003_0	8	4	Specialty Tier	1	2	010010		1	110100000010000000000101	30		90							2										30		34		34	14					355.71	25		25																																								25				25			25			
H1251	003	0	1	18	06	H1251_003_0	8	3	Non-Preferred Brand	1	2	100000		2	110100000010001000000001	30		90							2			90							30				34	14		70.00		210.00																								140.00																		70.00								70.00				
H1251	003	0	1	18	06	H1251_003_0	8	1	Generic	1	2	010000		2	010100000010001000000100	30		90							2			90							30		34					6.00		18.00																								12.00																		6.00					6.00							
H1251	003	0	1	18	06	H1251_003_0	8	2	Preferred Brand	1	2	000001		2	110100000010001000000001	30		90							2			90							30				34	14		45.00		135.00																								90.00																		45.00								45.00				
H1251	004	0	1	18	06	H1251_004_0	8	4	Specialty Tier	1	4	010010	1	1	110100000010000000000101	30		90							2										30		34		34	14					395.71	25		25																																								25				25			25			
H1251	004	0	1	18	06	H1251_004_0	8	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							2			90							30				34	14		65.00		195.00																								130.00																		65.00								65.00				
H1251	004	0	1	18	06	H1251_004_0	8	1	Generic	1	4	010000	1	2	010100000010001000000100	30		90							2			90							30		34					4.00		12.00																								8.00																		4.00					4.00							
H1251	004	0	1	18	06	H1251_004_0	8	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				34	14		30.00		90.00																								60.00																		30.00								30.00				
H1264	004	0	1	02	01	H1264_004_0	7	4	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
H1264	004	0	1	02	01	H1264_004_0	7	3	Non-Preferred Brand	1	4	100000	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		60.00	120.00	180.00																													60.00	120.00	120.00							180.00				60.00								60.00				
H1264	004	0	1	02	01	H1264_004_0	7	1	Generic	3	4	010010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		3.00	6.00	9.00																													3.00	6.00	0.00							9.00				3.00					3.00			3.00		1		
H1264	004	0	1	02	01	H1264_004_0	7	2	Preferred Brand	1	4	000001	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		30.00	60.00	90.00																													30.00	60.00	60.00							90.00				30.00								30.00				
H1264	004	0	1	02	01	H1264_004_0	7	1	Generic	1	4	010010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		3.00	6.00	9.00																													3.00	6.00	0.00							9.00				3.00					3.00			3.00				
H1264	007	0	1	01	01	H1264_007_0	6	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	31													31			31			31		31		31	14					707.00	25																														25							25					25				25			25			
H1264	007	0	1	01	01	H1264_007_0	6	1	Preferred Generic	1	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
H1264	007	0	1	01	01	H1264_007_0	6	2	Preferred Brand	1	4	010001	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		45.00	90.00	135.00																													45.00	90.00	90.00							135.00				45.00					45.00			45.00				
H1264	007	0	1	01	01	H1264_007_0	6	3	Non-Preferred Brand	1	4	110000	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		95.00	190.00	285.00																													95.00	190.00	190.00							285.00				95.00					95.00			95.00				
H1264	008	0	1	01	01	H1264_008_0	7	2	Preferred Brand	1	4	000001	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		30.00	60.00	90.00																													30.00	60.00	60.00							90.00				30.00								30.00				
H1264	008	0	1	01	01	H1264_008_0	7	3	Non-Preferred Brand	1	4	100000	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		60.00	120.00	180.00																													60.00	120.00	120.00							180.00				60.00								60.00				
H1264	008	0	1	01	01	H1264_008_0	7	4	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
H1264	008	0	1	01	01	H1264_008_0	7	1	Generic	1	4	010010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		3.00	6.00	9.00																													3.00	6.00	0.00							9.00				3.00					3.00			3.00				
H1264	008	0	1	01	01	H1264_008_0	7	1	Generic	3	4	010010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		3.00	6.00	9.00																													3.00	6.00	0.00							9.00				3.00					3.00			3.00		1		
H1264	018	0	1	01	01	H1264_018_0	6	1	Preferred Generic	1	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
H1264	018	0	1	01	01	H1264_018_0	6	2	Preferred Brand	1	4	010001	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		45.00	90.00	135.00																													45.00	90.00	90.00							135.00				45.00					45.00			45.00				
H1264	018	0	1	01	01	H1264_018_0	6	3	Non-Preferred Brand	1	4	110000	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		95.00	190.00	285.00																													95.00	190.00	190.00							285.00				95.00					95.00			95.00				
H1264	018	0	1	01	01	H1264_018_0	6	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	31													31			31			31		31		31	14					707.00	25																														25							25					25				25			25			
H1266	001	0	1	09	04	H1266_001_0	9	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H1266	001	0	1	09	04	H1266_001_0	9	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					723.00	33																														33							33					33				33			33	2	3	
H1266	001	0	1	09	04	H1266_001_0	9	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H1266	001	0	1	09	04	H1266_001_0	9	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H1266	001	0	1	09	04	H1266_001_0	9	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00		2	3	1
H1266	001	0	1	09	04	H1266_001_0	9	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					635.00	33																														33							33					33				33			33			
H1266	001	0	1	09	04	H1266_001_0	9	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H1266	001	0	1	09	04	H1266_001_0	9	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H1286	002	0	1	02	01	H1286_002_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H1286	002	0	1	02	01	H1286_002_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H1286	002	0	1	02	01	H1286_002_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					403.00	33		33																														33							33			33				33			33			
H1286	002	0	1	02	01	H1286_002_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H1286	002	0	1	02	01	H1286_002_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H1291	001	0	1	09	04	H1291_001_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H1291	001	0	1	09	04	H1291_001_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H1291	001	0	1	09	04	H1291_001_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H1291	001	0	1	09	04	H1291_001_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H1291	001	0	1	09	04	H1291_001_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					762.00	33																														33							33					33				33			33	2	3	
H1291	001	0	1	09	04	H1291_001_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1291	001	0	1	09	04	H1291_001_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					642.00	33																														33							33					33				33			33			
H1291	001	0	1	09	04	H1291_001_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1291	001	0	1	09	04	H1291_001_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H1291	001	0	1	09	04	H1291_001_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H1302	001	0	1	04	01	H1302_001_0	6	1	Generic	1	4	010000	1	2	000010110110001000000110				30		90	30		90	1			90							30		31	14												8.00		24.00						10.00		30.00								24.00																		10.00					8.00							
H1302	001	0	1	04	01	H1302_001_0	6	2	Preferred Brand	1	4	000001	1	2	100010110110001000000001				30		90	30		90	1			90							30				31	14										43.00		129.00						45.00		135.00								129.00																		45.00								43.00				
H1302	001	0	1	04	01	H1302_001_0	6	3	Non-Preferred Brand	1	4	100000	1	2	100010110110001000000001				30		90	30		90	1			90							30				31	14										93.00		279.00						95.00		285.00								279.00																		95.00								93.00				
H1302	001	0	1	04	01	H1302_001_0	6	4	Specialty Tier	1	4	010010	1	1	100010110110001000000111				30		90	30		90	1			90							30		31	14	31	14													592.96	33		33					592.36	33		33							33																	33				33			33			
H1302	006	0	1	04	01	H1302_006_0	6	1	Generic	1	4	010000	1	2	000010110110001000000110				30		90	30		90	1			90							30		31	14												8.00		24.00						10.00		30.00								24.00																		10.00					8.00							
H1302	006	0	1	04	01	H1302_006_0	6	2	Preferred Brand	1	4	000001	1	2	100010110110001000000001				30		90	30		90	1			90							30				31	14										43.00		129.00						45.00		135.00								129.00																		45.00								43.00				
H1302	006	0	1	04	01	H1302_006_0	6	3	Non-Preferred Brand	1	4	100000	1	2	100010110110001000000001				30		90	30		90	1			90							30				31	14										93.00		279.00						95.00		285.00								279.00																		95.00								93.00				
H1302	006	0	1	04	01	H1302_006_0	6	4	Specialty Tier	1	4	010010	1	1	100010110110001000000111				30		90	30		90	1			90							30		31	14	31	14													558.11	33		33					558.11	33		33							33																	33				33			33			
H1303	001	0	1	04	01	H1303_001_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H1303	001	0	1	04	01	H1303_001_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H1303	001	0	1	04	01	H1303_001_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					503.00	33		33																														33							33			33				33			33			
H1303	001	0	1	04	01	H1303_001_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H1303	001	0	1	04	01	H1303_001_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H1304	002	0	1	04	01	H1304_002_0	12	1	Preferred Generic	1	3	001000		2	010100000010101000000100	30		90							1	30		90							30		31				0.25	7.50		22.50																					0.25	7.50		15.00																		7.50				0.24	7.50							
H1304	002	0	1	04	01	H1304_002_0	12	2	Non-Preferred Generic	1	3	000100		2	010100000010101000000100	30		90							1	30		90							30		31				1.10	33.00		99.00																					1.10	33.00		66.00																		33.00				1.06	33.00							
H1304	002	0	1	04	01	H1304_002_0	12	5	Specialty Tier	1	3	101101		1	110000000010100000000101	30										30									30		31		31	14					440.00	29																							29																			29				29			29			
H1304	002	0	1	04	01	H1304_002_0	12	4	Non-Preferred Brand	1	3	100000		2	110100000010101000000001	30		90							1	30		90							30				31	14	3.00	90.00		270.00																					3.00	90.00		225.00																		90.00							2.90	90.00				
H1304	002	0	1	04	01	H1304_002_0	12	3	Preferred Brand	1	3	000001		2	110100000010101000000001	30		90							1	30		90							30				31	14	1.50	45.00		135.00																					1.50	45.00		112.50																		45.00							1.45	45.00				
H1304	002	0	1	04	01	H1304_002_0	12	6	Injectable Drugs	1	3	101101		1	110000000010100000000101	30										30									30		31		31	14					49.00	29																							29																			29				29			29			
H1304	004	0	1	04	01	H1304_004_0	10	5	Specialty Tier	1	4	101101	1	1	110000000010100000000101	30										30									30		31		31	14					402.00	33																							33																			33				33			33			
H1304	004	0	1	04	01	H1304_004_0	10	6	Injectable Drugs	1	4	101101	1	1	110000000010100000000101	30										30									30		31		31	14					59.00	33																							33																			33				33			33			
H1304	004	0	1	04	01	H1304_004_0	10	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		90							1	30		90							30		31				0.16	5.00		15.00																					0.16	5.00		10.00																		5.00				0.16	5.00					1		
H1304	004	0	1	04	01	H1304_004_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							1	30		90							30		31				0.16	5.00		15.00																					0.16	5.00		10.00																		5.00				0.16	5.00							
H1304	004	0	1	04	01	H1304_004_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							1	30		90							30		31				1.10	33.00		99.00																					1.10	33.00		66.00																		33.00				1.06	33.00							
H1304	004	0	1	04	01	H1304_004_0	10	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							1	30		90							30				31	14	1.50	45.00		135.00																					1.50	45.00		112.50																		45.00							1.45	45.00				
H1304	004	0	1	04	01	H1304_004_0	10	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							1	30		90							30				31	14	3.00	90.00		270.00																					3.00	90.00		225.00																		90.00							2.90	90.00				
H1304	009	0	1	04	01	H1304_009_0	10	6	Injectable Drugs	1	3	101101		1	110000000010100000000101	30										30									30		31		31	14					49.00	29																							29																			29				29			29			
H1304	009	0	1	04	01	H1304_009_0	10	5	Specialty Tier	1	3	101101		1	110000000010100000000101	30										30									30		31		31	14					440.00	29																							29																			29				29			29			
H1304	009	0	1	04	01	H1304_009_0	10	4	Non-Preferred Brand	1	3	100000		2	110100000010101000000001	30		90							1	30		90							30				31	14	3.00	90.00		270.00																					3.00	90.00		225.00																		90.00							2.90	90.00				
H1304	009	0	1	04	01	H1304_009_0	10	3	Preferred Brand	1	3	000001		2	110100000010101000000001	30		90							1	30		90							30				31	14	1.50	45.00		135.00																					1.50	45.00		112.50																		45.00							1.45	45.00				
H1304	009	0	1	04	01	H1304_009_0	10	2	Non-Preferred Generic	1	3	000100		2	010100000010101000000100	30		90							1	30		90							30		31				1.10	33.00		99.00																					1.10	33.00		66.00																		33.00				1.06	33.00							
H1304	009	0	1	04	01	H1304_009_0	10	1	Preferred Generic	1	3	001000		2	010100000010101000000100	30		90							1	30		90							30		31				0.25	7.50		22.50																					0.25	7.50		15.00																		7.50				0.24	7.50							
H1304	010	0	1	04	01	H1304_010_0	12	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							1	30		90							30		31				0.16	5.00		15.00																					0.16	5.00		10.00																		5.00				0.16	5.00							
H1304	010	0	1	04	01	H1304_010_0	12	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							1	30		90							30		31				1.10	33.00		99.00																					1.10	33.00		66.00																		33.00				1.06	33.00							
H1304	010	0	1	04	01	H1304_010_0	12	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		90							1	30		90							30		31				0.16	5.00		15.00																					0.16	5.00		10.00																		5.00				0.16	5.00					1		
H1304	010	0	1	04	01	H1304_010_0	12	6	Injectable Drugs	1	4	101101	1	1	110000000010100000000101	30										30									30		31		31	14					59.00	33																							33																			33				33			33			
H1304	010	0	1	04	01	H1304_010_0	12	5	Specialty Tier	1	4	101101	1	1	110000000010100000000101	30										30									30		31		31	14					402.00	33																							33																			33				33			33			
H1304	010	0	1	04	01	H1304_010_0	12	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							1	30		90							30				31	14	1.50	45.00		135.00																					1.50	45.00		112.50																		45.00							1.45	45.00				
H1304	010	0	1	04	01	H1304_010_0	12	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							1	30		90							30				31	14	3.00	90.00		270.00																					3.00	90.00		225.00																		90.00							2.90	90.00				
H1350	001	0	1	01	01	H1350_001_0	6	4	Specialty Tier	1	4	010010	1	1	100010110110001000000101				30		90	30		90	1			90							30		31		31	14													616.28	33		33					616.28	33		33							33																	33				33			33			
H1350	001	0	1	01	01	H1350_001_0	6	2	Preferred Brand	1	4	000001	1	2	100010110110001000000001				30		90	30		90	1			90							30				31	14										31.00		93.00						33.00		99.00								93.00																		33.00								31.00				
H1350	001	0	1	01	01	H1350_001_0	6	1	Generic	3	4	010000	1	2	000010110110001000000110				30		90	30		90	1			90							30		31	14												6.00		18.00						8.00		24.00								18.00																		8.00					6.00					1		
H1350	001	0	1	01	01	H1350_001_0	6	3	Non-Preferred Brand	1	4	100000	1	2	100010110110001000000001				30		90	30		90	1			90							30				31	14										70.00		210.00						72.00		216.00								210.00																		72.00								70.00				
H1350	001	0	1	01	01	H1350_001_0	6	1	Generic	1	4	010000	1	2	000010110110001000000110				30		90	30		90	1			90							30		31	14												6.00		18.00						8.00		24.00								18.00																		8.00					6.00							
H1350	010	0	1	01	01	H1350_010_0	6	4	Specialty Tier	1	3	010010		1	100010110110001000000101				30		90	30		90	1			90							30		31		31	14													515.36	25		25					515.36	25		25							25																	25				25			25			
H1350	010	0	1	01	01	H1350_010_0	6	2	Preferred Brand	1	3	000001		2	100010110110001000000001				30		90	30		90	1			90							30				31	14										31.00		93.00						33.00		99.00								93.00																		33.00								31.00				
H1350	010	0	1	01	01	H1350_010_0	6	1	Generic	1	3	010000		2	000010110110001000000110				30		90	30		90	1			90							30		31	14												6.00		18.00						8.00		24.00								18.00																		8.00					6.00							
H1350	010	0	1	01	01	H1350_010_0	6	3	Non-Preferred Brand	1	3	100000		2	100010110110001000000001				30		90	30		90	1			90							30				31	14										70.00		210.00						72.00		216.00								210.00																		72.00								70.00				
H1350	011	0	1	01	01	H1350_011_0	5	2	Preferred Brand	1	3	000001		2	100010110110001000000001				30		90	30		90	1			90							30				31	14										43.00		129.00						45.00		135.00								129.00																		45.00								43.00				
H1350	011	0	1	01	01	H1350_011_0	5	1	Generic	1	3	010000		2	000010110110001000000110				30		90	30		90	1			90							30		31	14												8.00		24.00						10.00		30.00								24.00																		10.00					8.00							
H1350	011	0	1	01	01	H1350_011_0	5	3	Non-Preferred Brand	1	3	100000		2	100010110110001000000001				30		90	30		90	1			90							30				31	14										93.00		279.00						95.00		285.00								279.00																		95.00								93.00				
H1350	011	0	1	01	01	H1350_011_0	5	4	Specialty Tier	1	3	010010		1	100010110110001000000111				30		90	30		90	1			90							30		31	14	31	14													522.20	28		28					522.20	28		28							28																	28				28			28			
H1365	001	0	1	04	01	H1365_001_0	8	5	Specialty Tier	1	4	010010	1	1	100011111110111000000111				30	60	90	30	60	90	1	30	60	90							30		31	14	31	14													600.00	33	33	33					600.00	33	33	33					33	33	33																	33				33			33			
H1365	001	0	1	04	01	H1365_001_0	8	4	Non-Preferred Brand	1	4	100100	1	2	100011111110111000000111				30	60	90	30	60	90	1	30	60	90							30		31	14	31	14										80.00	160.00	240.00						80.00	160.00	240.00						80.00	160.00	200.00																		80.00					80.00			80.00				
H1365	001	0	1	04	01	H1365_001_0	8	2	Non-Preferred Generic	1	4	000101	1	2	100011111110111000000111				30	60	90	30	60	90	1	30	60	90							30		31	14	31	14										6.00	12.00	18.00						10.00	20.00	30.00						10.00	20.00	25.00																		10.00					10.00			10.00				
H1365	001	0	1	04	01	H1365_001_0	8	1	Preferred Generic	1	4	001001	1	2	100011111110111000000111				30	60	90	30	60	90	1	30	60	90							30		31	14	31	14										0.00	0.00	0.00						4.00	8.00	12.00						4.00	8.00	10.00																		4.00					4.00			4.00				
H1365	001	0	1	04	01	H1365_001_0	8	3	Preferred Brand	1	4	000101	1	2	100011111110111000000111				30	60	90	30	60	90	1	30	60	90							30		31	14	31	14										40.00	80.00	120.00						40.00	80.00	120.00						40.00	80.00	100.00																		40.00					40.00			40.00				
H1365	002	0	1	04	01	H1365_002_0	7	1	Preferred Generic	1	4	001001	1	2	100011111110111000000111				30	60	90	30	60	90	1	30	60	90							30		31	14	31	14										0.00	0.00	0.00						4.00	8.00	12.00						4.00	8.00	10.00																		4.00					4.00			4.00				
H1365	002	0	1	04	01	H1365_002_0	7	2	Non-Preferred Generic	1	4	000101	1	2	100011111110111000000111				30	60	90	30	60	90	1	30	60	90							30		31	14	31	14										6.00	12.00	18.00						10.00	20.00	30.00						10.00	20.00	25.00																		10.00					10.00			10.00				
H1365	002	0	1	04	01	H1365_002_0	7	3	Preferred Brand	1	4	000101	1	2	100011111110111000000111				30	60	90	30	60	90	1	30	60	90							30		31	14	31	14										40.00	80.00	120.00						40.00	80.00	120.00						40.00	80.00	100.00																		40.00					40.00			40.00				
H1365	002	0	1	04	01	H1365_002_0	7	4	Non-Preferred Brand	1	4	100100	1	2	100011111110111000000111				30	60	90	30	60	90	1	30	60	90							30		31	14	31	14										80.00	160.00	240.00						80.00	160.00	240.00						80.00	160.00	200.00																		80.00					80.00			80.00				
H1365	002	0	1	04	01	H1365_002_0	7	5	Specialty Tier	1	4	010010	1	1	100011111110111000000111				30	60	90	30	60	90	1	30	60	90							30		31	14	31	14													600.00	33	33	33					600.00	33	33	33					33	33	33																	33				33			33			
H1365	003	0	1	04	01	H1365_003_0	7	1	Preferred Generic	1	4	001001	1	2	100011111110111000000111				30	60	90	30	60	90	1	30	60	90							30		31	14	31	14										0.00	0.00	0.00						4.00	8.00	12.00						4.00	8.00	10.00																		4.00					4.00			4.00				
H1365	003	0	1	04	01	H1365_003_0	7	2	Non-Preferred Generic	1	4	000101	1	2	100011111110111000000111				30	60	90	30	60	90	1	30	60	90							30		31	14	31	14										6.00	12.00	18.00						10.00	20.00	30.00						10.00	20.00	25.00																		10.00					10.00			10.00				
H1365	003	0	1	04	01	H1365_003_0	7	3	Preferred Brand	1	4	000101	1	2	100011111110111000000111				30	60	90	30	60	90	1	30	60	90							30		31	14	31	14										40.00	80.00	120.00						40.00	80.00	120.00						40.00	80.00	100.00																		40.00					40.00			40.00				
H1365	003	0	1	04	01	H1365_003_0	7	4	Non-Preferred Brand	1	4	100100	1	2	100011111110111000000111				30	60	90	30	60	90	1	30	60	90							30		31	14	31	14										80.00	160.00	240.00						80.00	160.00	240.00						80.00	160.00	200.00																		80.00					80.00			80.00				
H1365	003	0	1	04	01	H1365_003_0	7	5	Specialty Tier	1	4	010010	1	1	100011111110111000000111				30	60	90	30	60	90	1	30	60	90							30		31	14	31	14													600.00	33	33	33					600.00	33	33	33					33	33	33																	33				33			33			
H1406	013	0	1	01	01	H1406_013_0	5	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H1406	013	0	1	01	01	H1406_013_0	5	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		42.00		126.00																													42.00		116.00					42.00		126.00				42.00					42.00			42.00		2	2	
H1406	013	0	1	01	01	H1406_013_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	
H1406	013	0	1	01	01	H1406_013_0	5	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					671.00	33																														33							33					33				33			33			
H1406	013	0	1	01	01	H1406_013_0	5	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H1406	013	0	1	01	01	H1406_013_0	5	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		42.00		126.00																													42.00		116.00					42.00		126.00				42.00					42.00			42.00				
H1406	013	0	1	01	01	H1406_013_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H1406	013	0	1	01	01	H1406_013_0	5	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					855.00	33																														33							33					33				33			33	2	3	
H1406	022	0	1	02	01	H1406_022_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H1406	022	0	1	02	01	H1406_022_0	7	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		41.00		123.00																													41.00		113.00					41.00		123.00				41.00					41.00			41.00				
H1406	022	0	1	02	01	H1406_022_0	7	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H1406	022	0	1	02	01	H1406_022_0	7	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					514.00	33																														33							33					33				33			33			
H1406	022	0	1	02	01	H1406_022_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H1406	022	0	1	02	01	H1406_022_0	7	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					605.00	33																														33							33					33				33			33	2	3	
H1406	022	0	1	02	01	H1406_022_0	7	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H1406	022	0	1	02	01	H1406_022_0	7	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		41.00		123.00																													41.00		113.00					41.00		123.00				41.00					41.00			41.00		2	2	
H1406	026	0	1	01	01	H1406_026_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H1406	026	0	1	01	01	H1406_026_0	5	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1168.00	33																														33							33					33				33			33	2	3	
H1406	026	0	1	01	01	H1406_026_0	5	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H1406	026	0	1	01	01	H1406_026_0	5	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H1406	026	0	1	01	01	H1406_026_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H1406	026	0	1	01	01	H1406_026_0	5	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					969.00	33																														33							33					33				33			33			
H1406	026	0	1	01	01	H1406_026_0	5	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H1406	026	0	1	01	01	H1406_026_0	5	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H1406	027	0	1	01	01	H1406_027_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H1406	027	0	1	01	01	H1406_027_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H1406	027	0	1	01	01	H1406_027_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					778.00	33																														33							33					33				33			33			
H1406	027	0	1	01	01	H1406_027_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H1406	027	0	1	01	01	H1406_027_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H1406	027	0	1	01	01	H1406_027_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H1406	027	0	1	01	01	H1406_027_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H1406	027	0	1	01	01	H1406_027_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					891.00	33																														33							33					33				33			33	2	3	
H1406	027	0	1	01	01	H1406_027_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H1406	027	0	1	01	01	H1406_027_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H1406	028	0	1	01	01	H1406_028_0	5	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H1406	028	0	1	01	01	H1406_028_0	5	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					882.00	33																														33							33					33				33			33	2	3	
H1406	028	0	1	01	01	H1406_028_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H1406	028	0	1	01	01	H1406_028_0	5	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					758.00	33																														33							33					33				33			33			
H1406	028	0	1	01	01	H1406_028_0	5	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H1406	028	0	1	01	01	H1406_028_0	5	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		42.00		126.00																													42.00		116.00					42.00		126.00				42.00					42.00			42.00				
H1406	028	0	1	01	01	H1406_028_0	5	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		42.00		126.00																													42.00		116.00					42.00		126.00				42.00					42.00			42.00		2	2	
H1406	028	0	1	01	01	H1406_028_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H1406	029	0	1	01	01	H1406_029_0	5	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H1406	029	0	1	01	01	H1406_029_0	5	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					738.00	33																														33							33					33				33			33			
H1406	029	0	1	01	01	H1406_029_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	
H1406	029	0	1	01	01	H1406_029_0	5	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H1406	029	0	1	01	01	H1406_029_0	5	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H1406	029	0	1	01	01	H1406_029_0	5	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					755.00	33																														33							33					33				33			33	2	3	
H1406	029	0	1	01	01	H1406_029_0	5	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H1406	029	0	1	01	01	H1406_029_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H1415	021	0	1	02	01	H1415_021_0	7	3	Preferred Brand	1	4	000001	1	2	111100000010001000000001	30	60	90							2			90							30				31	14		45.00	90.00	135.00																								125.00																		45.00								45.00				
H1415	021	0	1	02	01	H1415_021_0	7	4	Non-Preferred Brand	1	4	100100	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		75.00	150.00	225.00																								215.00																		75.00					75.00			75.00				
H1415	021	0	1	02	01	H1415_021_0	7	5	Specialty Tier	1	4	010010	1	1	111100000010001000000101	30	60	90							2			90							30		31		31	14					314.30	33	33	33																							33																	33				33			33			
H1415	021	0	1	02	01	H1415_021_0	7	1	Preferred Generic	1	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					5.00	10.00	15.00																								6.00																		5.00					5.00							
H1415	021	0	1	02	01	H1415_021_0	7	2	Non-Preferred Generic	1	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		5.00	10.00	15.00																								6.00																		5.00					5.00			5.00				
H1416	007	0	1	01	01	H1416_007_0	6	1	Preferred Generic	1	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
H1416	007	0	1	01	01	H1416_007_0	6	2	Preferred Brand	1	4	010001	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		45.00	90.00	135.00																													45.00	90.00	90.00							135.00				45.00					45.00			45.00				
H1416	007	0	1	01	01	H1416_007_0	6	3	Non-Preferred Brand	1	4	110000	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		95.00	190.00	285.00																													95.00	190.00	190.00							285.00				95.00					95.00			95.00				
H1416	007	0	1	01	01	H1416_007_0	6	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	31													31			31			31		31		31	14					707.00	25																														25							25					25				25			25			
H1416	009	0	1	02	01	H1416_009_0	7	1	Generic	1	4	010010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		3.00	6.00	9.00																													3.00	6.00	0.00							9.00				3.00					3.00			3.00				
H1416	009	0	1	02	01	H1416_009_0	7	2	Preferred Brand	1	4	000001	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		39.00	78.00	117.00																													39.00	78.00	78.00							117.00				39.00								39.00				
H1416	009	0	1	02	01	H1416_009_0	7	4	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
H1416	009	0	1	02	01	H1416_009_0	7	3	Non-Preferred Brand	1	4	100000	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		69.00	138.00	207.00																													69.00	138.00	138.00							207.00				69.00								69.00				
H1416	019	0	1	01	01	H1416_019_0	7	3	Non-Preferred Brand	1	4	100000	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		69.00	138.00	207.00																													69.00	138.00	138.00							207.00				69.00								69.00				
H1416	019	0	1	01	01	H1416_019_0	7	2	Preferred Brand	1	4	000001	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		39.00	78.00	117.00																													39.00	78.00	78.00							117.00				39.00								39.00				
H1416	019	0	1	01	01	H1416_019_0	7	1	Generic	1	4	010010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		3.00	6.00	9.00																													3.00	6.00	0.00							9.00				3.00					3.00			3.00				
H1416	019	0	1	01	01	H1416_019_0	7	4	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
H1417	002	0	1	04	01	H1417_002_0	9	4	Non-Preferred Brand	1	3	100000		2	100010110110101000000001				30		90	30		90	1	30		90							30				31	14										95.00		285.00						95.00		285.00						95.00		285.00																		95.00								95.00				
H1417	002	0	1	04	01	H1417_002_0	9	5	Specialty Tier	1	3	000001		1	100010110110101000000001				30		90	30		90	1	30		90							30				31	14													612.00	29		29					612.00	29		29					29		29																	29							29			
H1417	002	0	1	04	01	H1417_002_0	9	3	Preferred Brand	1	3	000001		2	100010110110101000000001				30		90	30		90	1	30		90							30				31	14										45.00		135.00						45.00		135.00						45.00		135.00																		45.00								45.00				
H1417	002	0	1	04	01	H1417_002_0	9	2	Non-Preferred Generic	1	3	000100		2	000010110110101000000100				30		90	30		90	1	30		90							30		31													33.00		99.00						33.00		99.00						33.00		99.00																		33.00					33.00							
H1417	002	0	1	04	01	H1417_002_0	9	1	Preferred Generic	1	3	001000		2	000010110110101000000100				30		90	30		90	1	30		90							30		31													0.00		0.00						7.00		21.00						7.00		21.00																		7.00					7.00							
H1417	004	0	1	04	01	H1417_004_0	9	1	Preferred Generic	1	3	001000		2	000010110110101000000100				30		90	30		90	1	30		90							30		31													0.00		0.00						7.00		21.00						7.00		21.00																		7.00					7.00							
H1417	004	0	1	04	01	H1417_004_0	9	2	Non-Preferred Generic	1	3	000100		2	000010110110101000000100				30		90	30		90	1	30		90							30		31													33.00		99.00						33.00		99.00						33.00		99.00																		33.00					33.00							
H1417	004	0	1	04	01	H1417_004_0	9	3	Preferred Brand	1	3	000001		2	100010110110101000000001				30		90	30		90	1	30		90							30				31	14										45.00		135.00						45.00		135.00						45.00		135.00																		45.00								45.00				
H1417	004	0	1	04	01	H1417_004_0	9	5	Specialty Tier	1	3	100000		1	100010110110101000000001				30		90	30		90	1	30		90							30				31	14													331.00	28		28					331.00	28		28					28		28																	28							28			
H1417	004	0	1	04	01	H1417_004_0	9	4	Non-Preferred Brand	1	3	100000		2	100010110110101000000001				30		90	30		90	1	30		90							30				31	14										95.00		285.00						95.00		285.00						95.00		285.00																		95.00								95.00				
H1418	002	0	1	04	01	H1418_002_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H1418	002	0	1	04	01	H1418_002_0	5	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H1418	002	0	1	04	01	H1418_002_0	5	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1418	002	0	1	04	01	H1418_002_0	5	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1418	002	0	1	04	01	H1418_002_0	5	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H1418	002	0	1	04	01	H1418_002_0	5	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					999.00	33																														33							33					33				33			33	2	3	
H1418	002	0	1	04	01	H1418_002_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	3	1
H1418	002	0	1	04	01	H1418_002_0	5	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					862.00	33																														33							33					33				33			33			
H1418	007	0	1	04	01	H1418_007_0	4	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H1418	007	0	1	04	01	H1418_007_0	4	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		38.00		114.00																													38.00		104.00					38.00		114.00				38.00					38.00			38.00				
H1418	007	0	1	04	01	H1418_007_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H1418	007	0	1	04	01	H1418_007_0	4	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1002.00	33																														33							33					33				33			33			
H1418	007	0	1	04	01	H1418_007_0	4	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1285.00	33																														33							33					33				33			33	2	3	
H1418	007	0	1	04	01	H1418_007_0	4	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H1418	007	0	1	04	01	H1418_007_0	4	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		38.00		114.00																													38.00		104.00					38.00		114.00				38.00					38.00			38.00		2	2	
H1418	007	0	1	04	01	H1418_007_0	4	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H1418	008	0	1	04	01	H1418_008_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1418	008	0	1	04	01	H1418_008_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1418	008	0	1	04	01	H1418_008_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					608.00	33																														33							33					33				33			33			
H1418	008	0	1	04	01	H1418_008_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00		2	3	1
H1418	008	0	1	04	01	H1418_008_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H1418	008	0	1	04	01	H1418_008_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H1418	008	0	1	04	01	H1418_008_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H1418	008	0	1	04	01	H1418_008_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					672.00	33																														33							33					33				33			33	2	3	
H1418	008	0	1	04	01	H1418_008_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H1418	008	0	1	04	01	H1418_008_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H1419	001	0	1	01	01	H1419_001_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H1419	001	0	1	01	01	H1419_001_0	6	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H1419	001	0	1	01	01	H1419_001_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H1419	001	0	1	01	01	H1419_001_0	6	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					7.00	14.00	21.00																													7.00	14.00	14.00					7.00	14.00	21.00					7.00				7.00							
H1419	001	0	1	01	01	H1419_001_0	6	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					322.33	33	33	33																												33	33	33					33	33	33				33			33			33			
H1463	003	0	1	01	01	H1463_003_0	8	4	Non-Preferred Brand	1	3	100000		2	100010110110101000000001				30		90	30		90	1	30		90							30				31	14										95.00		285.00						95.00		285.00						95.00		285.00																		95.00								95.00				
H1463	003	0	1	01	01	H1463_003_0	8	3	Preferred Brand	1	3	000001		2	100010110110101000000001				30		90	30		90	1	30		90							30				31	14										45.00		135.00						45.00		135.00						45.00		135.00																		45.00								45.00				
H1463	003	0	1	01	01	H1463_003_0	8	2	Non-Preferred Generic	1	3	000100		2	000010110110101000000100				30		90	30		90	1	30		90							30		31													33.00		99.00						33.00		99.00						33.00		99.00																		33.00					33.00							
H1463	003	0	1	01	01	H1463_003_0	8	1	Preferred Generic	1	3	001000		2	000010110110101000000100				30		90	30		90	1	30		90							30		31													0.00		0.00						7.00		21.00						7.00		21.00																		7.00					7.00							
H1463	003	0	1	01	01	H1463_003_0	8	5	Specialty Tier	1	3	100000		1	100010110110101000000001				30		90	30		90	1	30		90							30				31	14													539.00	29		29					539.00	29		29					29		29																	29							29			
H1463	009	0	1	02	01	H1463_009_0	5	4	Non-Preferred Brand	1	3	100000		2	100010110110101000000001				30		90	30		90	1	30		90							30				31	14										95.00		285.00						95.00		285.00						95.00		285.00																		95.00								95.00				
H1463	009	0	1	02	01	H1463_009_0	5	5	Specialty Tier	1	3	100000		1	100010110110101000000001				30		90	30		90	1	30		90							30				31	14													331.00	29		29					331.00	29		29					29		29																	29							29			
H1463	009	0	1	02	01	H1463_009_0	5	3	Preferred Brand	1	3	000001		2	100010110110101000000001				30		90	30		90	1	30		90							30				31	14										45.00		135.00						45.00		135.00						45.00		135.00																		45.00								45.00				
H1463	009	0	1	02	01	H1463_009_0	5	2	Non-Preferred Generic	1	3	000100		2	000010110110101000000100				30		90	30		90	1	30		90							30		31													33.00		99.00						33.00		99.00						33.00		99.00																		33.00					33.00							
H1463	009	0	1	02	01	H1463_009_0	5	1	Preferred Generic	1	3	001000		2	000010110110101000000100				30		90	30		90	1	30		90							30		31													0.00		0.00						7.00		21.00						7.00		21.00																		7.00					7.00							
H1468	007	0	1	01	01	H1468_007_0	4	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		36.00		108.00																													36.00		98.00					36.00		108.00				36.00					36.00			36.00		2	2	
H1468	007	0	1	01	01	H1468_007_0	4	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H1468	007	0	1	01	01	H1468_007_0	4	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					967.00	33																														33							33					33				33			33	2	3	
H1468	007	0	1	01	01	H1468_007_0	4	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H1468	007	0	1	01	01	H1468_007_0	4	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					793.00	33																														33							33					33				33			33			
H1468	007	0	1	01	01	H1468_007_0	4	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H1468	007	0	1	01	01	H1468_007_0	4	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		36.00		108.00																													36.00		98.00					36.00		108.00				36.00					36.00			36.00				
H1468	007	0	1	01	01	H1468_007_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H1509	001	0	1	04	01	H1509_001_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H1509	001	0	1	04	01	H1509_001_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H1509	001	0	1	04	01	H1509_001_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H1509	001	0	1	04	01	H1509_001_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H1509	001	0	1	04	01	H1509_001_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					528.00	33		33																														33							33			33				33			33			
H1509	007	0	1	04	01	H1509_007_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H1509	007	0	1	04	01	H1509_007_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H1509	007	0	1	04	01	H1509_007_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H1509	007	0	1	04	01	H1509_007_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H1509	007	0	1	04	01	H1509_007_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					546.00	33		33																														33							33			33				33			33			
H1509	009	0	1	04	01	H1509_009_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H1509	009	0	1	04	01	H1509_009_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H1509	009	0	1	04	01	H1509_009_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H1509	009	0	1	04	01	H1509_009_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H1509	009	0	1	04	01	H1509_009_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					389.00	33		33																														33							33			33				33			33			
H1509	010	0	1	04	01	H1509_010_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H1509	010	0	1	04	01	H1509_010_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H1509	010	0	1	04	01	H1509_010_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					7.00		21.00																															14.00							21.00				7.00					7.00							
H1509	010	0	1	04	01	H1509_010_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					4.00		12.00																															8.00							12.00				4.00					4.00							
H1509	010	0	1	04	01	H1509_010_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					537.00	33		33																														33							33			33				33			33			
H1510	001	0	1	04	01	H1510_001_0	4	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H1510	001	0	1	04	01	H1510_001_0	4	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H1510	001	0	1	04	01	H1510_001_0	4	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H1510	001	0	1	04	01	H1510_001_0	4	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H1510	001	0	1	04	01	H1510_001_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1061.00	33																														33							33					33				33			33			
H1510	001	0	1	04	01	H1510_001_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H1510	001	0	1	04	01	H1510_001_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H1510	001	0	1	04	01	H1510_001_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1510	001	0	1	04	01	H1510_001_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1510	001	0	1	04	01	H1510_001_0	4	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1225.00	33																														33							33					33				33			33	2	3	
H1510	004	0	1	04	01	H1510_004_0	4	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					980.00	33																														33							33					33				33			33	2	3	
H1510	004	0	1	04	01	H1510_004_0	4	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H1510	004	0	1	04	01	H1510_004_0	4	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H1510	004	0	1	04	01	H1510_004_0	4	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H1510	004	0	1	04	01	H1510_004_0	4	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H1510	004	0	1	04	01	H1510_004_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					859.00	33																														33							33					33				33			33			
H1510	004	0	1	04	01	H1510_004_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1510	004	0	1	04	01	H1510_004_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1510	004	0	1	04	01	H1510_004_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H1510	004	0	1	04	01	H1510_004_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H1510	005	0	1	04	01	H1510_005_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H1510	005	0	1	04	01	H1510_005_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H1510	005	0	1	04	01	H1510_005_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1510	005	0	1	04	01	H1510_005_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1510	005	0	1	04	01	H1510_005_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					992.00	33																														33							33					33				33			33	2	3	
H1510	005	0	1	04	01	H1510_005_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H1510	005	0	1	04	01	H1510_005_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H1510	005	0	1	04	01	H1510_005_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H1510	005	0	1	04	01	H1510_005_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H1510	005	0	1	04	01	H1510_005_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					830.00	33																														33							33					33				33			33			
H1510	008	0	1	04	01	H1510_008_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					604.00	33																														33							33					33				33			33	2	3	
H1510	008	0	1	04	01	H1510_008_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H1510	008	0	1	04	01	H1510_008_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H1510	008	0	1	04	01	H1510_008_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H1510	008	0	1	04	01	H1510_008_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1510	008	0	1	04	01	H1510_008_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					554.00	33																														33							33					33				33			33			
H1510	008	0	1	04	01	H1510_008_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H1510	008	0	1	04	01	H1510_008_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H1510	008	0	1	04	01	H1510_008_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H1510	008	0	1	04	01	H1510_008_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1510	009	0	1	04	01	H1510_009_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H1510	009	0	1	04	01	H1510_009_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					923.00	33																														33							33					33				33			33	2	3	
H1510	009	0	1	04	01	H1510_009_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H1510	009	0	1	04	01	H1510_009_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H1510	009	0	1	04	01	H1510_009_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H1510	009	0	1	04	01	H1510_009_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					828.00	33																														33							33					33				33			33			
H1510	009	0	1	04	01	H1510_009_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1510	009	0	1	04	01	H1510_009_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H1510	009	0	1	04	01	H1510_009_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H1510	009	0	1	04	01	H1510_009_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1517	004	0	1	04	01	H1517_004_0	11	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00					45.00			45.00				
H1517	004	0	1	04	01	H1517_004_0	11	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				4.00	8.00	12.00																						4.00	8.00	6.00																		4.00					4.00							
H1517	004	0	1	04	01	H1517_004_0	11	5	Injectable Drugs	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					90.00	33	33	33																					33	33	33																	33				33			33			
H1517	004	0	1	04	01	H1517_004_0	11	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H1517	004	0	1	04	01	H1517_004_0	11	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	14.00	10.50																		7.00					7.00							
H1517	004	0	1	04	01	H1517_004_0	11	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					925.00	33																							33																			33				33			33			
H1517	005	0	1	04	01	H1517_005_0	11	5	Injectable Drugs	1	3	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					90.00	33	33	33																					33	33	33																	33				33			33			
H1517	005	0	1	04	01	H1517_005_0	11	4	Non-Preferred Brand	1	3	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		85.00	170.00	255.00																						85.00	170.00	212.50																		85.00					85.00			85.00				
H1517	005	0	1	04	01	H1517_005_0	11	3	Preferred Brand	1	3	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		40.00	80.00	120.00																						40.00	80.00	100.00																		40.00					40.00			40.00				
H1517	005	0	1	04	01	H1517_005_0	11	6	Specialty Tier	1	3	010010		1	110000000010100000000111	30										30									30		34	14	34	14					925.00	33																							33																			33				33			33			
H1517	005	0	1	04	01	H1517_005_0	11	2	Non-Preferred Generic	1	3	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				6.00	12.00	18.00																						6.00	12.00	9.00																		6.00					6.00							
H1517	005	0	1	04	01	H1517_005_0	11	1	Preferred Generic	1	3	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				4.00	8.00	12.00																						4.00	8.00	6.00																		4.00					4.00							
H1537	001	0	1	04	01	H1537_001_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					713.00	33		33																														33							33			33				33			33			
H1537	001	0	1	04	01	H1537_001_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H1537	001	0	1	04	01	H1537_001_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					7.00		21.00																															14.00							21.00				7.00					7.00							
H1537	001	0	1	04	01	H1537_001_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H1537	001	0	1	04	01	H1537_001_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H1595	002	0	1	04	01	H1595_002_0	21	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							1	30		90							30				31	14		70.00		140.00																						70.00		140.00																		70.00								70.00				
H1595	002	0	1	04	01	H1595_002_0	21	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							1	30		90							30				31	14		35.00		70.00																						35.00		70.00																		35.00								35.00				
H1595	002	0	1	04	01	H1595_002_0	21	1	Generic	1	4	010000	1	2	010100000010101000000100	30		90							1	30		90							30		31					6.00		12.00																						6.00		12.00																		6.00					6.00							
H1595	002	0	1	04	01	H1595_002_0	21	4	Specialty Tier	1	4	010010	1	1	110100000010101000000101	30		90							1	30		90							30		31		31	14					25.00	25		25																					25		25																	25				25			25			
H1607	001	0	1	04	01	H1607_001_0	12	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				4.00	8.00	12.00																						4.00	8.00	6.00																		4.00					4.00							
H1607	001	0	1	04	01	H1607_001_0	12	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				8.00	16.00	24.00																						8.00	16.00	12.00																		8.00					8.00							
H1607	001	0	1	04	01	H1607_001_0	12	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00					45.00			45.00				
H1607	001	0	1	04	01	H1607_001_0	12	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H1607	001	0	1	04	01	H1607_001_0	12	5	Injectable Drugs	1	4	010010	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H1607	001	0	1	04	01	H1607_001_0	12	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					1092.00	33																							33																			33				33			33			
H1607	008	0	1	04	01	H1607_008_0	12	1	Preferred Generic	1	3	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				4.00	8.00	12.00																						4.00	8.00	6.00																		4.00					4.00							
H1607	008	0	1	04	01	H1607_008_0	12	2	Non-Preferred Generic	1	3	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				8.00	16.00	24.00																						8.00	16.00	12.00																		8.00					8.00							
H1607	008	0	1	04	01	H1607_008_0	12	3	Preferred Brand	1	3	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		40.00	80.00	120.00																						40.00	80.00	100.00																		40.00					40.00			40.00				
H1607	008	0	1	04	01	H1607_008_0	12	4	Non-Preferred Brand	1	3	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H1607	008	0	1	04	01	H1607_008_0	12	5	Injectable Drugs	1	3	010010		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H1607	008	0	1	04	01	H1607_008_0	12	6	Specialty Tier	1	3	010010		1	110000000010100000000111	30										30									30		34	14	34	14					1092.00	33																							33																			33				33			33			
H1607	009	0	1	04	01	H1607_009_0	12	5	Injectable Drugs	1	3	010010		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H1607	009	0	1	04	01	H1607_009_0	12	6	Specialty Tier	1	3	010010		1	110000000010100000000111	30										30									30		34	14	34	14					1092.00	33																							33																			33				33			33			
H1607	009	0	1	04	01	H1607_009_0	12	1	Preferred Generic	1	3	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				4.00	8.00	12.00																						4.00	8.00	6.00																		4.00					4.00							
H1607	009	0	1	04	01	H1607_009_0	12	2	Non-Preferred Generic	1	3	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				8.00	16.00	24.00																						8.00	16.00	12.00																		8.00					8.00							
H1607	009	0	1	04	01	H1607_009_0	12	3	Preferred Brand	1	3	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		40.00	80.00	120.00																						40.00	80.00	100.00																		40.00					40.00			40.00				
H1607	009	0	1	04	01	H1607_009_0	12	4	Non-Preferred Brand	1	3	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H1607	010	0	1	04	01	H1607_010_0	12	4	Non-Preferred Brand	1	3	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H1607	010	0	1	04	01	H1607_010_0	12	1	Preferred Generic	1	3	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				4.00	8.00	12.00																						4.00	8.00	6.00																		4.00					4.00							
H1607	010	0	1	04	01	H1607_010_0	12	2	Non-Preferred Generic	1	3	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				8.00	16.00	24.00																						8.00	16.00	12.00																		8.00					8.00							
H1607	010	0	1	04	01	H1607_010_0	12	3	Preferred Brand	1	3	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		40.00	80.00	120.00																						40.00	80.00	100.00																		40.00					40.00			40.00				
H1607	010	0	1	04	01	H1607_010_0	12	5	Injectable Drugs	1	3	010010		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H1607	010	0	1	04	01	H1607_010_0	12	6	Specialty Tier	1	3	010010		1	110000000010100000000111	30										30									30		34	14	34	14					1092.00	33																							33																			33				33			33			
H1607	011	0	1	04	01	H1607_011_0	12	4	Non-Preferred Brand	1	3	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H1607	011	0	1	04	01	H1607_011_0	12	3	Preferred Brand	1	3	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		40.00	80.00	120.00																						40.00	80.00	100.00																		40.00					40.00			40.00				
H1607	011	0	1	04	01	H1607_011_0	12	2	Non-Preferred Generic	1	3	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				8.00	16.00	24.00																						8.00	16.00	12.00																		8.00					8.00							
H1607	011	0	1	04	01	H1607_011_0	12	1	Preferred Generic	1	3	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				4.00	8.00	12.00																						4.00	8.00	6.00																		4.00					4.00							
H1607	011	0	1	04	01	H1607_011_0	12	5	Injectable Drugs	1	3	010010		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H1607	011	0	1	04	01	H1607_011_0	12	6	Specialty Tier	1	3	010010		1	110000000010100000000111	30										30									30		34	14	34	14					1092.00	33																							33																			33				33			33			
H1608	001	0	1	04	01	H1608_001_0	9	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													3.00		9.00						7.00		21.00						3.00		9.00																		7.00					7.00							
H1608	001	0	1	04	01	H1608_001_0	9	2	Non-Preferred Generic	1	4	000100	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													7.00		21.00						7.00		21.00						7.00		21.00																		7.00					7.00							
H1608	001	0	1	04	01	H1608_001_0	9	3	Preferred Brand	1	4	000001	1	2	100010110110101000000001				30		90	30		90	2	30		90							30				31	14										42.00		126.00						42.00		126.00						42.00		126.00																		42.00								42.00				
H1608	001	0	1	04	01	H1608_001_0	9	4	Non-Preferred Brand	1	4	100100	1	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										85.00		255.00						85.00		255.00						85.00		255.00																		85.00					85.00			85.00				
H1608	001	0	1	04	01	H1608_001_0	9	5	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													850.94	33							850.94	33																										33				33			33			
H1608	004	0	1	04	01	H1608_004_0	7	3	Preferred Brand	1	4	000001	1	2	100010110110101000000001				30		90	30		90	2	30		90							30				31	14										40.00		120.00						40.00		120.00						40.00		120.00																		40.00								40.00				
H1608	004	0	1	04	01	H1608_004_0	7	5	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													750.09	33							750.09	33																										33				33			33			
H1608	004	0	1	04	01	H1608_004_0	7	2	Non-Preferred Generic	1	4	000100	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													4.00		12.00						4.00		12.00						4.00		12.00																		4.00					4.00							
H1608	004	0	1	04	01	H1608_004_0	7	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													2.00		6.00						4.00		12.00						2.00		6.00																		4.00					4.00							
H1608	004	0	1	04	01	H1608_004_0	7	4	Non-Preferred Brand	1	4	100100	1	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										80.00		240.00						80.00		240.00						80.00		240.00																		80.00					80.00			80.00				
H1609	001	0	1	01	01	H1609_001_0	8	5	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													583.60	33							583.60	33																										33				33			33			
H1609	001	0	1	01	01	H1609_001_0	8	4	Non-Preferred Brand	1	4	100100	1	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										85.00		255.00						85.00		255.00						85.00		255.00																		85.00					85.00			85.00				
H1609	001	0	1	01	01	H1609_001_0	8	3	Preferred Brand	1	4	000001	1	2	100010110110101000000001				30		90	30		90	2	30		90							30				31	14										42.00		126.00						42.00		126.00						42.00		126.00																		42.00								42.00				
H1609	001	0	1	01	01	H1609_001_0	8	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													3.00		9.00						7.00		21.00						3.00		9.00																		7.00					7.00							
H1609	001	0	1	01	01	H1609_001_0	8	2	Non-Preferred Generic	1	4	000100	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													7.00		21.00						7.00		21.00						7.00		21.00																		7.00					7.00							
H1609	009	0	1	01	01	H1609_009_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													2.00		6.00						4.00		12.00						2.00		6.00																		4.00					4.00							
H1609	009	0	1	01	01	H1609_009_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													4.00		12.00						4.00		12.00						4.00		12.00																		4.00					4.00							
H1609	009	0	1	01	01	H1609_009_0	6	3	Preferred Brand	1	4	000001	1	2	100010110110101000000001				30		90	30		90	2	30		90							30				31	14										40.00		120.00						40.00		120.00						40.00		120.00																		40.00								40.00				
H1609	009	0	1	01	01	H1609_009_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										80.00		240.00						80.00		240.00						80.00		240.00																		80.00					80.00			80.00				
H1609	009	0	1	01	01	H1609_009_0	6	5	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													499.78	33							499.78	33																										33				33			33			
H1609	010	0	1	01	01	H1609_010_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										80.00		240.00						80.00		240.00						80.00		240.00																		80.00					80.00			80.00				
H1609	010	0	1	01	01	H1609_010_0	6	3	Preferred Brand	1	4	000001	1	2	100010110110101000000001				30		90	30		90	2	30		90							30				31	14										40.00		120.00						40.00		120.00						40.00		120.00																		40.00								40.00				
H1609	010	0	1	01	01	H1609_010_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													4.00		12.00						4.00		12.00						4.00		12.00																		4.00					4.00							
H1609	010	0	1	01	01	H1609_010_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													2.00		6.00						4.00		12.00						2.00		6.00																		4.00					4.00							
H1609	010	0	1	01	01	H1609_010_0	6	5	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													499.78	33							499.78	33																										33				33			33			
H1659	001	0	1	04	01	H1659_001_0	5	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							1	30		90							30				31	14		40.00		120.00																						40.00		80.00																		40.00								40.00				
H1659	001	0	1	04	01	H1659_001_0	5	4	Specialty Tier	1	4	100001	1	1	110100000010101000000001	30		90							1	30		90							30				31	14					200.00	33		33																					33		33																	33							33			
H1659	001	0	1	04	01	H1659_001_0	5	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							1	30		90							30				31	14		80.00		240.00																						80.00		160.00																		80.00								80.00				
H1659	001	0	1	04	01	H1659_001_0	5	1	Generic	1	4	010000	1	2	010100000010101000000100	30		90							1	30		90							30		31					8.00		24.00																						0.00		0.00																		8.00					8.00							
H1659	002	0	1	04	01	H1659_002_0	5	4	Specialty Tier	1	4	100001	1	1	110100000010101000000001	30		90							1	30		90							30				31	14					200.00	33		33																					33		33																	33							33			
H1659	002	0	1	04	01	H1659_002_0	5	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							1	30		90							30				31	14		80.00		240.00																						80.00		160.00																		80.00								80.00				
H1659	002	0	1	04	01	H1659_002_0	5	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							1	30		90							30				31	14		40.00		120.00																						40.00		80.00																		40.00								40.00				
H1659	002	0	1	04	01	H1659_002_0	5	1	Generic	1	4	010000	1	2	010100000010101000000100	30		90							1	30		90							30		31					8.00		24.00																						0.00		0.00																		8.00					8.00							
H1659	003	0	1	04	01	H1659_003_0	6	1	Generic	1	4	010000	1	2	010100000010101000000100	30		90							1	30		90							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00							
H1659	003	0	1	04	01	H1659_003_0	6	4	Specialty Tier	1	4	100001	1	1	110100000010101000000001	30		90							1	30		90							30				31	14					200.00	33		33																					33		33																	33							33			
H1659	003	0	1	04	01	H1659_003_0	6	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							1	30		90							30				31	14		45.00		135.00																						45.00		90.00																		45.00								45.00				
H1659	003	0	1	04	01	H1659_003_0	6	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							1	30		90							30				31	14		95.00		285.00																						95.00		190.00																		95.00								95.00				
H1666	001	0	1	04	01	H1666_001_0	8	2	Non-Preferred Generic	1	3	000100		2	000010110110001000000100				30		90	30		90	1			90							30		31													10.00		25.00						10.00		30.00								25.00																		10.00					10.00							
H1666	001	0	1	04	01	H1666_001_0	8	1	Preferred Generic	1	3	001000		2	000010110110001000000100				30		90	30		90	1			90							30		31													3.00		7.50						3.00		9.00								7.50																		3.00					3.00							
H1666	001	0	1	04	01	H1666_001_0	8	3	Preferred Brand	1	3	000001		2	100010110110001000000001				30		90	30		90	1			90							30				31	14										43.00		107.50						43.00		129.00								107.50																		43.00								43.00				
H1666	001	0	1	04	01	H1666_001_0	8	4	Non-Preferred Brand	1	3	100000		2	100010110110001000000001				30		90	30		90	1			90							30				31	14										95.00		237.50						95.00		285.00								237.50																		95.00								95.00				
H1666	001	0	1	04	01	H1666_001_0	8	5	Specialty Tier	1	3	010010		1	100010110110000000000101				30		90	30		90	1										30		31		31	14													970.00	25		25					970.00	25		25																								25				25			25			
H1666	002	0	1	04	01	H1666_002_0	7	2	Non-Preferred Generic	1	3	000100		2	000010110110001000000100				30		90	30		90	1			90							30		31													10.00		25.00						10.00		30.00								25.00																		10.00					10.00							
H1666	002	0	1	04	01	H1666_002_0	7	1	Preferred Generic	1	3	001000		2	000010110110001000000100				30		90	30		90	1			90							30		31													3.00		7.50						3.00		9.00								7.50																		3.00					3.00							
H1666	002	0	1	04	01	H1666_002_0	7	3	Preferred Brand	1	3	000001		2	100010110110001000000001				30		90	30		90	1			90							30				31	14										43.00		107.50						43.00		129.00								107.50																		43.00								43.00				
H1666	002	0	1	04	01	H1666_002_0	7	5	Specialty Tier	1	3	010010		1	100010110110000000000101				30		90	30		90	1										30		31		31	14													970.00	25		25					970.00	25		25																								25				25			25			
H1666	002	0	1	04	01	H1666_002_0	7	4	Non-Preferred Brand	1	3	100000		2	100010110110001000000001				30		90	30		90	1			90							30				31	14										95.00		237.50						95.00		285.00								237.50																		95.00								95.00				
H1666	003	0	1	04	01	H1666_003_0	7	1	Preferred Generic	1	3	001000		2	000010110110001000000100				30		90	30		90	1			90							30		31													3.00		7.50						3.00		9.00								7.50																		3.00					3.00							
H1666	003	0	1	04	01	H1666_003_0	7	2	Non-Preferred Generic	1	3	000100		2	000010110110001000000100				30		90	30		90	1			90							30		31													10.00		25.00						10.00		30.00								25.00																		10.00					10.00							
H1666	003	0	1	04	01	H1666_003_0	7	4	Non-Preferred Brand	1	3	100000		2	100010110110001000000001				30		90	30		90	1			90							30				31	14										95.00		237.50						95.00		285.00								237.50																		95.00								95.00				
H1666	003	0	1	04	01	H1666_003_0	7	3	Preferred Brand	1	3	000001		2	100010110110001000000001				30		90	30		90	1			90							30				31	14										43.00		107.50						43.00		129.00								107.50																		43.00								43.00				
H1666	003	0	1	04	01	H1666_003_0	7	5	Specialty Tier	1	3	010010		1	100010110110000000000101				30		90	30		90	1										30		31		31	14													970.00	25		25					970.00	25		25																								25				25			25			
H1681	001	0	1	04	01	H1681_001_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		75.00		225.00																													75.00		215.00					75.00		225.00				75.00					75.00			75.00				
H1681	001	0	1	04	01	H1681_001_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					621.00	28																														28							28					28				28			28			
H1681	001	0	1	04	01	H1681_001_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		2.00		6.00																													0.00		0.00					2.00		6.00				2.00					2.00			2.00				
H1681	001	0	1	04	01	H1681_001_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00				
H1681	001	0	1	04	01	H1681_001_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		35.00		105.00																													35.00		95.00					35.00		105.00				35.00					35.00			35.00				
H1681	002	0	1	04	01	H1681_002_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H1681	002	0	1	04	01	H1681_002_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H1681	002	0	1	04	01	H1681_002_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H1681	002	0	1	04	01	H1681_002_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H1681	002	0	1	04	01	H1681_002_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1242.00	33																														33							33					33				33			33			
H1681	002	0	1	04	01	H1681_002_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H1681	002	0	1	04	01	H1681_002_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1681	002	0	1	04	01	H1681_002_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1326.00	33																														33							33					33				33			33	2	3	
H1681	002	0	1	04	01	H1681_002_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H1681	002	0	1	04	01	H1681_002_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H1681	004	0	1	04	01	H1681_004_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H1681	004	0	1	04	01	H1681_004_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H1681	004	0	1	04	01	H1681_004_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					820.00	33																														33							33					33				33			33			
H1681	004	0	1	04	01	H1681_004_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H1681	004	0	1	04	01	H1681_004_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1681	004	0	1	04	01	H1681_004_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H1681	004	0	1	04	01	H1681_004_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H1681	004	0	1	04	01	H1681_004_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H1681	004	0	1	04	01	H1681_004_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					879.00	33																														33							33					33				33			33	2	3	
H1681	004	0	1	04	01	H1681_004_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H1681	005	0	1	04	01	H1681_005_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H1681	005	0	1	04	01	H1681_005_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H1681	005	0	1	04	01	H1681_005_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H1681	005	0	1	04	01	H1681_005_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H1681	005	0	1	04	01	H1681_005_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1024.00	33																														33							33					33				33			33	2	3	
H1681	005	0	1	04	01	H1681_005_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H1681	005	0	1	04	01	H1681_005_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1681	005	0	1	04	01	H1681_005_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H1681	005	0	1	04	01	H1681_005_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H1681	005	0	1	04	01	H1681_005_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					921.00	33																														33							33					33				33			33			
H1681	006	0	1	04	01	H1681_006_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					863.00	33																														33							33					33				33			33	2	3	
H1681	006	0	1	04	01	H1681_006_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H1681	006	0	1	04	01	H1681_006_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H1681	006	0	1	04	01	H1681_006_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H1681	006	0	1	04	01	H1681_006_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H1681	006	0	1	04	01	H1681_006_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					796.00	33																														33							33					33				33			33			
H1681	006	0	1	04	01	H1681_006_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H1681	006	0	1	04	01	H1681_006_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1681	006	0	1	04	01	H1681_006_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H1681	006	0	1	04	01	H1681_006_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H1716	001	0	1	04	01	H1716_001_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		82.00		246.00																													82.00		236.00					82.00		246.00				82.00					82.00			82.00		2	3	
H1716	001	0	1	04	01	H1716_001_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		41.00		123.00																													41.00		113.00					41.00		123.00				41.00					41.00			41.00		2	2	
H1716	001	0	1	04	01	H1716_001_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H1716	001	0	1	04	01	H1716_001_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00		2	3	1
H1716	001	0	1	04	01	H1716_001_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					933.00	33																														33							33					33				33			33	2	3	
H1716	001	0	1	04	01	H1716_001_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		82.00		246.00																													82.00		236.00					82.00		246.00				82.00					82.00			82.00				
H1716	001	0	1	04	01	H1716_001_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		41.00		123.00																													41.00		113.00					41.00		123.00				41.00					41.00			41.00				
H1716	001	0	1	04	01	H1716_001_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H1716	001	0	1	04	01	H1716_001_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H1716	001	0	1	04	01	H1716_001_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					856.00	33																														33							33					33				33			33			
H1716	006	0	1	04	01	H1716_006_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00				
H1716	006	0	1	04	01	H1716_006_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					988.00	33																														33							33					33				33			33	2	3	
H1716	006	0	1	04	01	H1716_006_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		88.00		264.00																													88.00		254.00					88.00		264.00				88.00					88.00			88.00		2	3	
H1716	006	0	1	04	01	H1716_006_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		44.00		132.00																													44.00		122.00					44.00		132.00				44.00					44.00			44.00		2	2	
H1716	006	0	1	04	01	H1716_006_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		13.00		39.00																													0.00		0.00					13.00		39.00				13.00					13.00			13.00		2	2	
H1716	006	0	1	04	01	H1716_006_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00		2	3	1
H1716	006	0	1	04	01	H1716_006_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					900.00	33																														33							33					33				33			33			
H1716	006	0	1	04	01	H1716_006_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		88.00		264.00																													88.00		254.00					88.00		264.00				88.00					88.00			88.00				
H1716	006	0	1	04	01	H1716_006_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		44.00		132.00																													44.00		122.00					44.00		132.00				44.00					44.00			44.00				
H1716	006	0	1	04	01	H1716_006_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		13.00		39.00																													0.00		0.00					13.00		39.00				13.00					13.00			13.00				
H1716	019	0	1	04	01	H1716_019_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H1716	019	0	1	04	01	H1716_019_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		42.00		126.00																													42.00		116.00					42.00		126.00				42.00					42.00			42.00				
H1716	019	0	1	04	01	H1716_019_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		84.00		252.00																													84.00		242.00					84.00		252.00				84.00					84.00			84.00				
H1716	019	0	1	04	01	H1716_019_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					819.00	33																														33							33					33				33			33			
H1716	019	0	1	04	01	H1716_019_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H1716	019	0	1	04	01	H1716_019_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		11.00		33.00																													0.00		0.00					11.00		33.00				11.00					11.00			11.00		2	2	
H1716	019	0	1	04	01	H1716_019_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		42.00		126.00																													42.00		116.00					42.00		126.00				42.00					42.00			42.00		2	2	
H1716	019	0	1	04	01	H1716_019_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		84.00		252.00																													84.00		242.00					84.00		252.00				84.00					84.00			84.00		2	3	
H1716	019	0	1	04	01	H1716_019_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					901.00	33																														33							33					33				33			33	2	3	
H1716	019	0	1	04	01	H1716_019_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		11.00		33.00																													0.00		0.00					11.00		33.00				11.00					11.00			11.00				
H1716	020	0	1	04	01	H1716_020_0	8	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										1.00		3.00						8.00		24.00													0.00		0.00					8.00		24.00				8.00					8.00			8.00				
H1716	020	0	1	04	01	H1716_020_0	8	2	Non-Preferred Generic	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										3.00		9.00						10.00		30.00													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H1716	020	0	1	04	01	H1716_020_0	8	3	Preferred Brand	1	4	000101	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													16.00	18		18					23.00	25		25												18		18					25		25			25				25			25			
H1716	020	0	1	04	01	H1716_020_0	8	4	Non-Preferred Brand	1	4	110000	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													92.00	30		30					94.00	50		50												30		30					50		50			50				50			50			
H1716	020	0	1	04	01	H1716_020_0	8	5	Specialty Tier	3	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													717.00	25							728.00	25														25							25					25				25			25	2	3	
H1716	020	0	1	04	01	H1716_020_0	8	2	Non-Preferred Generic	3	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										3.00		9.00						10.00		30.00													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	3	
H1716	020	0	1	04	01	H1716_020_0	8	3	Preferred Brand	3	4	000101	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													22.00	18		18					31.00	25		25												18		18					25		25			25				25			25	2	2	
H1716	020	0	1	04	01	H1716_020_0	8	4	Non-Preferred Brand	3	4	110000	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													120.00	30		30					122.00	50		50												30		30					50		50			50				50			50	2	3	
H1716	020	0	1	04	01	H1716_020_0	8	5	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													636.00	25							645.00	25														25							25					25				25			25			
H1806	001	0	1	04	01	H1806_001_0	4	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H1806	001	0	1	04	01	H1806_001_0	4	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H1806	001	0	1	04	01	H1806_001_0	4	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H1806	001	0	1	04	01	H1806_001_0	4	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1096.00	33																														33							33					33				33			33	2	3	
H1806	001	0	1	04	01	H1806_001_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H1806	001	0	1	04	01	H1806_001_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H1806	001	0	1	04	01	H1806_001_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1806	001	0	1	04	01	H1806_001_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1806	001	0	1	04	01	H1806_001_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					899.00	33																														33							33					33				33			33			
H1806	001	0	1	04	01	H1806_001_0	4	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H1806	002	0	1	04	01	H1806_002_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1806	002	0	1	04	01	H1806_002_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1806	002	0	1	04	01	H1806_002_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					700.00	33																														33							33					33				33			33			
H1806	002	0	1	04	01	H1806_002_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					846.00	33																														33							33					33				33			33	2	3	
H1806	002	0	1	04	01	H1806_002_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H1806	002	0	1	04	01	H1806_002_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H1806	002	0	1	04	01	H1806_002_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H1806	002	0	1	04	01	H1806_002_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	
H1806	002	0	1	04	01	H1806_002_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H1806	002	0	1	04	01	H1806_002_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H1806	005	0	1	04	01	H1806_005_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H1806	005	0	1	04	01	H1806_005_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1806	005	0	1	04	01	H1806_005_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1806	005	0	1	04	01	H1806_005_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					771.00	33																														33							33					33				33			33			
H1806	005	0	1	04	01	H1806_005_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H1806	005	0	1	04	01	H1806_005_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H1806	005	0	1	04	01	H1806_005_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H1806	005	0	1	04	01	H1806_005_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					844.00	33																														33							33					33				33			33	2	3	
H1806	005	0	1	04	01	H1806_005_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H1806	005	0	1	04	01	H1806_005_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H1806	007	0	1	04	01	H1806_007_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1806	007	0	1	04	01	H1806_007_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1806	007	0	1	04	01	H1806_007_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H1806	007	0	1	04	01	H1806_007_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H1806	007	0	1	04	01	H1806_007_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					911.00	33																														33							33					33				33			33	2	3	
H1806	007	0	1	04	01	H1806_007_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H1806	007	0	1	04	01	H1806_007_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H1806	007	0	1	04	01	H1806_007_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H1806	007	0	1	04	01	H1806_007_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					821.00	33																														33							33					33				33			33			
H1806	007	0	1	04	01	H1806_007_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H1846	001	0	1	04	01	H1846_001_0	5	2	Non-Preferred Generic	3	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		31	1	31	14		12.00	24.00	36.00																						12.00	24.00	24.00																		12.00					12.00			12.00		1		
H1846	001	0	1	04	01	H1846_001_0	5	2	Non-Preferred Generic	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		31	1	31	14		12.00	24.00	36.00																						12.00	24.00	24.00																		12.00					12.00			12.00				
H1846	001	0	1	04	01	H1846_001_0	5	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		31	1	31	14		45.00	90.00	135.00																						45.00	90.00	90.00																		45.00					45.00			45.00				
H1846	001	0	1	04	01	H1846_001_0	5	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		31	1	31	14		75.00	150.00	225.00																						75.00	150.00	150.00																		75.00					75.00			75.00				
H1846	001	0	1	04	01	H1846_001_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		31	1	31	14					426.00	33																							33																			33				33			33			
H1846	001	0	1	04	01	H1846_001_0	5	1	Preferred Generic	1	4	001001	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		31	1	31	14		0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00			0.00				
H1846	001	0	1	04	01	H1846_001_0	5	1	Preferred Generic	3	4	001001	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		31	1	31	14		0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00			0.00		1		
H1846	003	0	1	04	01	H1846_003_0	6	1	Preferred Generic	1	4	001001	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		31	1	31	14		0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00			0.00				
H1846	003	0	1	04	01	H1846_003_0	6	2	Non-Preferred Generic	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		31	1	31	14		12.00	24.00	36.00																						12.00	24.00	24.00																		12.00					12.00			12.00				
H1846	003	0	1	04	01	H1846_003_0	6	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		31	1	31	14		45.00	90.00	135.00																						45.00	90.00	90.00																		45.00					45.00			45.00				
H1846	003	0	1	04	01	H1846_003_0	6	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		31	1	31	14		75.00	150.00	225.00																						75.00	150.00	150.00																		75.00					75.00			75.00				
H1846	003	0	1	04	01	H1846_003_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		31	1	31	14					792.00	33																							33																			33				33			33			
H1849	015	0	1	01	01	H1849_015_0	10	6	Specialty Tier	1	3	010010		1	110000000010100000000111	30										30									30		34	14	34	14					819.00	33																							33																			33				33			33			
H1849	015	0	1	01	01	H1849_015_0	10	5	Injectable Drugs	1	3	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					60.00	33	33	33																					33	33	33																	33				33			33			
H1849	015	0	1	01	01	H1849_015_0	10	4	Non-Preferred Brand	1	3	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		90.00	180.00	270.00																						90.00	180.00	225.00																		90.00					90.00			90.00				
H1849	015	0	1	01	01	H1849_015_0	10	3	Preferred Brand	1	3	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		41.00	82.00	123.00																						41.00	82.00	102.50																		41.00					41.00			41.00				
H1849	015	0	1	01	01	H1849_015_0	10	2	Non-Preferred Generic	1	3	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				9.00	18.00	27.00																						9.00	18.00	13.50																		9.00					9.00							
H1849	015	0	1	01	01	H1849_015_0	10	1	Preferred Generic	1	3	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				5.00	10.00	15.00																						5.00	10.00	7.50																		5.00					5.00							
H1849	016	0	1	01	01	H1849_016_0	10	1	Preferred Generic	1	3	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				5.00	10.00	15.00																						5.00	10.00	7.50																		5.00					5.00							
H1849	016	0	1	01	01	H1849_016_0	10	2	Non-Preferred Generic	1	3	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				9.00	18.00	27.00																						9.00	18.00	13.50																		9.00					9.00							
H1849	016	0	1	01	01	H1849_016_0	10	3	Preferred Brand	1	3	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		41.00	82.00	123.00																						41.00	82.00	102.50																		41.00					41.00			41.00				
H1849	016	0	1	01	01	H1849_016_0	10	4	Non-Preferred Brand	1	3	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		90.00	180.00	270.00																						90.00	180.00	225.00																		90.00					90.00			90.00				
H1849	016	0	1	01	01	H1849_016_0	10	5	Injectable Drugs	1	3	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					60.00	33	33	33																					33	33	33																	33				33			33			
H1849	016	0	1	01	01	H1849_016_0	10	6	Specialty Tier	1	3	010010		1	110000000010100000000111	30										30									30		34	14	34	14					819.00	33																							33																			33				33			33			
H1903	011	0	1	01	01	H1903_011_0	6	1	Preferred Generic	1	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
H1903	011	0	1	01	01	H1903_011_0	6	2	Preferred Brand	1	4	010001	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		44.00	88.00	132.00																													44.00	88.00	88.00							132.00				44.00					44.00			44.00				
H1903	011	0	1	01	01	H1903_011_0	6	3	Non-Preferred Brand	1	4	110000	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		95.00	190.00	285.00																													95.00	190.00	190.00							285.00				95.00					95.00			95.00				
H1903	011	0	1	01	01	H1903_011_0	6	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	31													31			31			31		31		31	14					707.00	25																														25							25					25				25			25			
H1903	022	0	1	02	01	H1903_022_0	6	1	Generic	1	4	010010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		3.00	6.00	9.00																													3.00	6.00	0.00							9.00				3.00					3.00			3.00				
H1903	022	0	1	02	01	H1903_022_0	6	2	Preferred Brand	1	4	000001	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		35.00	70.00	105.00																													35.00	70.00	70.00							105.00				35.00								35.00				
H1903	022	0	1	02	01	H1903_022_0	6	3	Non-Preferred Brand	1	4	100000	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		79.00	158.00	237.00																													79.00	158.00	158.00							237.00				79.00								79.00				
H1903	022	0	1	02	01	H1903_022_0	6	4	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
H1906	001	0	1	09	04	H1906_001_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					845.00	33																														33							33					33				33			33	2	3	
H1906	001	0	1	09	04	H1906_001_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H1906	001	0	1	09	04	H1906_001_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H1906	001	0	1	09	04	H1906_001_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H1906	001	0	1	09	04	H1906_001_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00		2	3	1
H1906	001	0	1	09	04	H1906_001_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					775.00	33																														33							33					33				33			33			
H1906	001	0	1	09	04	H1906_001_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1906	001	0	1	09	04	H1906_001_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1906	001	0	1	09	04	H1906_001_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00				
H1906	001	0	1	09	04	H1906_001_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H1944	001	0	1	01	01	H1944_001_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					7.00		21.00																															14.00							21.00				7.00					7.00							
H1944	001	0	1	01	01	H1944_001_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					4.00		12.00																															8.00							12.00				4.00					4.00							
H1944	001	0	1	01	01	H1944_001_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					494.00	33		33																														33							33			33				33			33			
H1944	001	0	1	01	01	H1944_001_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H1944	001	0	1	01	01	H1944_001_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H1951	001	0	1	01	01	H1951_001_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H1951	001	0	1	01	01	H1951_001_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		35.00		105.00																													35.00		95.00					35.00		105.00				35.00					35.00			35.00				
H1951	001	0	1	01	01	H1951_001_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00				
H1951	001	0	1	01	01	H1951_001_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H1951	001	0	1	01	01	H1951_001_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					764.00	33																														33							33					33				33			33			
H1951	001	0	1	01	01	H1951_001_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H1951	001	0	1	01	01	H1951_001_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00		2	2	
H1951	001	0	1	01	01	H1951_001_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		35.00		105.00																													35.00		95.00					35.00		105.00				35.00					35.00			35.00		2	2	
H1951	001	0	1	01	01	H1951_001_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H1951	001	0	1	01	01	H1951_001_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					879.00	33																														33							33					33				33			33	2	3	
H1951	005	0	1	01	01	H1951_005_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		35.00		105.00																													35.00		95.00					35.00		105.00				35.00					35.00			35.00		2	2	
H1951	005	0	1	01	01	H1951_005_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H1951	005	0	1	01	01	H1951_005_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					862.00	33																														33							33					33				33			33	2	3	
H1951	005	0	1	01	01	H1951_005_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H1951	005	0	1	01	01	H1951_005_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00				
H1951	005	0	1	01	01	H1951_005_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		35.00		105.00																													35.00		95.00					35.00		105.00				35.00					35.00			35.00				
H1951	005	0	1	01	01	H1951_005_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H1951	005	0	1	01	01	H1951_005_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					763.00	33																														33							33					33				33			33			
H1951	005	0	1	01	01	H1951_005_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H1951	005	0	1	01	01	H1951_005_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00		2	2	
H1951	013	0	1	01	01	H1951_013_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H1951	013	0	1	01	01	H1951_013_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H1951	013	0	1	01	01	H1951_013_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1951	013	0	1	01	01	H1951_013_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1951	013	0	1	01	01	H1951_013_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					923.00	33																														33							33					33				33			33	2	3	
H1951	013	0	1	01	01	H1951_013_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H1951	013	0	1	01	01	H1951_013_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H1951	013	0	1	01	01	H1951_013_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H1951	013	0	1	01	01	H1951_013_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H1951	013	0	1	01	01	H1951_013_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					754.00	33																														33							33					33				33			33			
H1951	024	0	1	01	01	H1951_024_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H1951	024	0	1	01	01	H1951_024_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H1951	024	0	1	01	01	H1951_024_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1951	024	0	1	01	01	H1951_024_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00				
H1951	024	0	1	01	01	H1951_024_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					510.00	33																														33							33					33				33			33	2	3	
H1951	024	0	1	01	01	H1951_024_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00		2	3	1
H1951	024	0	1	01	01	H1951_024_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H1951	024	0	1	01	01	H1951_024_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H1951	024	0	1	01	01	H1951_024_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00		2	3	
H1951	024	0	1	01	01	H1951_024_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					464.00	33																														33							33					33				33			33			
H1951	025	0	1	01	01	H1951_025_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1014.00	33																														33							33					33				33			33	2	3	
H1951	025	0	1	01	01	H1951_025_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00		2	3	
H1951	025	0	1	01	01	H1951_025_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H1951	025	0	1	01	01	H1951_025_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H1951	025	0	1	01	01	H1951_025_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H1951	025	0	1	01	01	H1951_025_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					918.00	33																														33							33					33				33			33			
H1951	025	0	1	01	01	H1951_025_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00				
H1951	025	0	1	01	01	H1951_025_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1951	025	0	1	01	01	H1951_025_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H1951	025	0	1	01	01	H1951_025_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H1951	028	0	1	01	01	H1951_028_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H1951	028	0	1	01	01	H1951_028_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H1951	028	0	1	01	01	H1951_028_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H1951	028	0	1	01	01	H1951_028_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					730.00	33																														33							33					33				33			33			
H1951	028	0	1	01	01	H1951_028_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H1951	028	0	1	01	01	H1951_028_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1951	028	0	1	01	01	H1951_028_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H1951	028	0	1	01	01	H1951_028_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H1951	028	0	1	01	01	H1951_028_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					892.00	33																														33							33					33				33			33	2	3	
H1951	028	0	1	01	01	H1951_028_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H1951	032	0	1	01	01	H1951_032_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					525.00	25																														25							25					25				25			25			
H1951	032	0	1	01	01	H1951_032_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1951	032	0	1	01	01	H1951_032_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1951	032	0	1	01	01	H1951_032_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		41.00		123.00																													41.00		113.00					41.00		123.00				41.00					41.00			41.00				
H1951	032	0	1	01	01	H1951_032_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1951	033	0	1	01	01	H1951_033_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					606.00	25																														25							25					25				25			25			
H1951	033	0	1	01	01	H1951_033_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1951	033	0	1	01	01	H1951_033_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1951	033	0	1	01	01	H1951_033_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		38.00		114.00																													38.00		104.00					38.00		114.00				38.00					38.00			38.00				
H1951	033	0	1	01	01	H1951_033_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H1951	034	0	1	01	01	H1951_034_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1951	034	0	1	01	01	H1951_034_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1951	034	0	1	01	01	H1951_034_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		35.00		105.00																													35.00		95.00					35.00		105.00				35.00					35.00			35.00				
H1951	034	0	1	01	01	H1951_034_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		64.00		192.00																													64.00		182.00					64.00		192.00				64.00					64.00			64.00				
H1951	034	0	1	01	01	H1951_034_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					981.00	25																														25							25					25				25			25			
H1951	035	0	1	01	01	H1951_035_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					473.00	25																														25							25					25				25			25			
H1951	035	0	1	01	01	H1951_035_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1951	035	0	1	01	01	H1951_035_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1951	035	0	1	01	01	H1951_035_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		41.00		123.00																													41.00		113.00					41.00		123.00				41.00					41.00			41.00				
H1951	035	0	1	01	01	H1951_035_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1951	036	0	1	01	01	H1951_036_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					751.00	33																														33							33					33				33			33	2	3	
H1951	036	0	1	01	01	H1951_036_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H1951	036	0	1	01	01	H1951_036_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		35.00		105.00																													35.00		95.00					35.00		105.00				35.00					35.00			35.00		2	2	
H1951	036	0	1	01	01	H1951_036_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00		2	2	
H1951	036	0	1	01	01	H1951_036_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00		2	3	1
H1951	036	0	1	01	01	H1951_036_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					730.00	33																														33							33					33				33			33			
H1951	036	0	1	01	01	H1951_036_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H1951	036	0	1	01	01	H1951_036_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		35.00		105.00																													35.00		95.00					35.00		105.00				35.00					35.00			35.00				
H1951	036	0	1	01	01	H1951_036_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00				
H1951	036	0	1	01	01	H1951_036_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00				
H1951	037	0	1	01	01	H1951_037_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H1951	037	0	1	01	01	H1951_037_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H1951	037	0	1	01	01	H1951_037_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H1951	037	0	1	01	01	H1951_037_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H1951	037	0	1	01	01	H1951_037_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					758.00	33																														33							33					33				33			33	2	3	
H1951	037	0	1	01	01	H1951_037_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1951	037	0	1	01	01	H1951_037_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1951	037	0	1	01	01	H1951_037_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H1951	037	0	1	01	01	H1951_037_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H1951	037	0	1	01	01	H1951_037_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					734.00	33																														33							33					33				33			33			
H1951	038	0	1	01	01	H1951_038_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					864.00	33																														33							33					33				33			33	2	3	
H1951	038	0	1	01	01	H1951_038_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		3.00		9.00																													0.00		0.00					3.00		9.00				3.00					3.00			3.00				
H1951	038	0	1	01	01	H1951_038_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H1951	038	0	1	01	01	H1951_038_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		35.00		105.00																													35.00		95.00					35.00		105.00				35.00					35.00			35.00				
H1951	038	0	1	01	01	H1951_038_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H1951	038	0	1	01	01	H1951_038_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					753.00	33																														33							33					33				33			33			
H1951	038	0	1	01	01	H1951_038_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		3.00		9.00																													0.00		0.00					3.00		9.00				3.00					3.00			3.00		1		
H1951	038	0	1	01	01	H1951_038_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		1		
H1951	038	0	1	01	01	H1951_038_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		35.00		105.00																													35.00		95.00					35.00		105.00				35.00					35.00			35.00		2	2	
H1951	038	0	1	01	01	H1951_038_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H1951	039	0	1	01	01	H1951_039_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		3.00		9.00																													0.00		0.00					3.00		9.00				3.00					3.00			3.00				
H1951	039	0	1	01	01	H1951_039_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					856.00	33																														33							33					33				33			33	2	3	
H1951	039	0	1	01	01	H1951_039_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		35.00		105.00																													35.00		95.00					35.00		105.00				35.00					35.00			35.00				
H1951	039	0	1	01	01	H1951_039_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H1951	039	0	1	01	01	H1951_039_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					748.00	33																														33							33					33				33			33			
H1951	039	0	1	01	01	H1951_039_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H1951	039	0	1	01	01	H1951_039_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H1951	039	0	1	01	01	H1951_039_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		35.00		105.00																													35.00		95.00					35.00		105.00				35.00					35.00			35.00		2	2	
H1951	039	0	1	01	01	H1951_039_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		1		
H1951	039	0	1	01	01	H1951_039_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		3.00		9.00																													0.00		0.00					3.00		9.00				3.00					3.00			3.00		1		
H1951	041	0	1	01	01	H1951_041_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1951	041	0	1	01	01	H1951_041_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1951	041	0	1	01	01	H1951_041_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1951	041	0	1	01	01	H1951_041_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H1951	041	0	1	01	01	H1951_041_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					269.00	25																														25							25					25				25			25			
H1951	042	0	1	01	01	H1951_042_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					675.00	33																														33							33					33				33			33			
H1951	042	0	1	01	01	H1951_042_0	9	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H1951	042	0	1	01	01	H1951_042_0	9	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H1951	042	0	1	01	01	H1951_042_0	9	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00				
H1951	042	0	1	01	01	H1951_042_0	9	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					2255.00	33																														33							33					33				33			33	2	3	
H1951	042	0	1	01	01	H1951_042_0	9	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H1951	042	0	1	01	01	H1951_042_0	9	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H1951	042	0	1	01	01	H1951_042_0	9	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H1951	042	0	1	01	01	H1951_042_0	9	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H1951	042	0	1	01	01	H1951_042_0	9	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00		2	2	
H1961	001	0	1	01	01	H1961_001_0	5	3	Preferred Brand	1	4	000001	3	2	110100000010001000000001	30		90							2			90							30				31	14	1.17	35.00		105.00																								105.00																		35.00							1.13	35.00				
H1961	001	0	1	01	01	H1961_001_0	5	2	Non-Preferred Generic	1	4	000110	3	2	110100000010001000000101	30		90							2			90							30		31		31	14	.33	10.00		30.00																								30.00																		10.00				.32	10.00		.32	10.00				
H1961	001	0	1	01	01	H1961_001_0	5	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							2			90							30		31				.10	3.00		9.00																								9.00																		3.00				.10	3.00							
H1961	001	0	1	01	01	H1961_001_0	5	4	Non-Preferred Brand	1	4	100000	3	2	110100000010001000000001	30		90							2			90							30				31	14	1.83	55.00		165.00																								165.00																		55.00							1.77	55.00				
H1961	001	0	1	01	01	H1961_001_0	5	5	Specialty Tier	1	4	000010	1	1	110100000010001000000001	30		90							2			90							30				31	14					498.94	20		20																							20																	20							20			
H1961	001	0	1	01	01	H1961_001_0	5	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							2			90							30		31				.10	3.00		9.00																								9.00																		3.00				.10	3.00					1		
H1961	001	0	1	01	01	H1961_001_0	5	2	Non-Preferred Generic	3	4	000110	3	2	110100000010001000000101	30		90							2			90							30		31		31	14	.33	10.00		30.00																								30.00																		10.00				.33	10.00		.33	10.00		1		
H1961	002	0	1	01	01	H1961_002_0	6	2	Non-Preferred Generic	3	4	000110	3	2	110100000010001000000101	30		90							2			90							30		31		31	14	.33	10.00		30.00																								30.00																		10.00				.33	10.00		.33	10.00		1		
H1961	002	0	1	01	01	H1961_002_0	6	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							2			90							30		31				.10	3.00		9.00																								9.00																		3.00				.10	3.00					1		
H1961	002	0	1	01	01	H1961_002_0	6	5	Specialty Tier	1	4	000010	1	1	110100000010001000000001	30		90							2			90							30				31	14					1205.94	33		33																							33																	33							33			
H1961	002	0	1	01	01	H1961_002_0	6	3	Preferred Brand	1	4	000001	3	2	110100000010001000000001	30		90							2			90							30				31	14	1.17	35.00		105.00																								105.00																		35.00							1.13	35.00				
H1961	002	0	1	01	01	H1961_002_0	6	4	Non-Preferred Brand	1	4	100000	3	2	110100000010001000000001	30		90							2			90							30				31	14	2.67	80.00		240.00																								240.00																		80.00							2.58	80.00				
H1961	002	0	1	01	01	H1961_002_0	6	2	Non-Preferred Generic	1	4	000110	3	2	110100000010001000000101	30		90							2			90							30		31		31	14	.33	10.00		30.00																								30.00																		10.00				.32	10.00		.32	10.00				
H1961	002	0	1	01	01	H1961_002_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							2			90							30		31				.10	3.00		9.00																								9.00																		3.00				.10	3.00							
H1961	003	0	1	01	01	H1961_003_0	6	3	Preferred Brand	1	4	000001	3	1	110100000010001000000001	30		90							2			90							30				31	14					44.66	25		25																							25																	25							25			
H1961	003	0	1	01	01	H1961_003_0	6	2	Non-Preferred Generic	1	4	000110	3	1	110100000010001000000101	30		90							2			90							30		31		31	14					7.33	25		25																							25																	25				25			25			
H1961	003	0	1	01	01	H1961_003_0	6	1	Preferred Generic	1	4	001000	1	1	010100000010001000000100	30		90							2			90							30		31								2.65	25		25																							25																	25				25						
H1961	003	0	1	01	01	H1961_003_0	6	4	Non-Preferred Brand	1	4	100000	3	1	110100000010001000000001	30		90							2			90							30				31	14					47.66	25		25																							25																	25							25			
H1961	003	0	1	01	01	H1961_003_0	6	5	Specialty Tier	1	4	000010	1	1	110100000010001000000001	30		90							2			90							30				31	14					737.75	25		25																							25																	25							25			
H1961	007	0	1	01	01	H1961_007_0	5	5	Specialty Tier	1	4	000010	1	1	110100000010001000000001	30		90							2			90							30				31	14					515.27	20		20																							20																	20							20			
H1961	007	0	1	01	01	H1961_007_0	5	4	Non-Preferred Brand	1	4	100000	3	2	110100000010001000000001	30		90							2			90							30				31	14	1.83	55.00		165.00																								165.00																		55.00							1.77	55.00				
H1961	007	0	1	01	01	H1961_007_0	5	3	Preferred Brand	1	4	000001	3	2	110100000010001000000001	30		90							2			90							30				31	14	1.17	35.00		105.00																								105.00																		35.00							1.13	35.00				
H1961	007	0	1	01	01	H1961_007_0	5	2	Non-Preferred Generic	1	4	000110	3	2	110100000010001000000101	30		90							2			90							30		31		31	14	.33	10.00		30.00																								30.00																		10.00				.32	10.00			10.00				
H1961	007	0	1	01	01	H1961_007_0	5	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							2			90							30		31				.10	3.00		9.00																								9.00																		3.00				.10	3.00							
H1961	007	0	1	01	01	H1961_007_0	5	2	Non-Preferred Generic	3	4	000110	3	2	110100000010001000000101	30		90							2			90							30		31		31	14	.33	10.00		30.00																								30.00																		10.00				.33	10.00			10.00		1		
H1961	007	0	1	01	01	H1961_007_0	5	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							2			90							30		31				.10	3.00		9.00																								9.00																		3.00				.10	3.00					1		
H1961	008	0	1	01	01	H1961_008_0	6	5	Specialty Tier	1	4	000010	1	1	110100000010001000000001	30		90							2			90							30				31	14					739.74	25		25																							25																	25							25			
H1961	008	0	1	01	01	H1961_008_0	6	4	Non-Preferred Brand	1	4	100000	3	1	110100000010001000000001	30		90							2			90							30				31	14					48.61	25		25																							25																	25							25			
H1961	008	0	1	01	01	H1961_008_0	6	3	Preferred Brand	1	4	000001	3	1	110100000010001000000001	30		90							2			90							30				31	14					45.31	25		25																							25																	25							25			
H1961	008	0	1	01	01	H1961_008_0	6	2	Non-Preferred Generic	1	4	000110	3	1	110100000010001000000101	30		90							2			90							30		31		31	14					7.52	25		25																							25																	25				25			25			
H1961	008	0	1	01	01	H1961_008_0	6	1	Preferred Generic	1	4	001000	1	1	010100000010001000000100	30		90							2			90							30		31								2.75	25		25																							25																	25				25						
H1994	001	0	1	02	01	H1994_001_0	11	1	Generic	1	4	010000	1	2	011100000010000000000100	30	60	90							1										30		31					5.00	10.00	15.00																																										5.00					5.00							
H1994	001	0	1	02	01	H1994_001_0	11	2	Preferred Brand	1	4	000001	1	2	111100000010000000000001	30	60	90							1										30				31	14		45.00	90.00	135.00																																										45.00								45.00				
H1994	001	0	1	02	01	H1994_001_0	11	3	Non-Preferred Brand	1	4	100000	1	2	111100000010000000000001	30	60	90							1										30				31	14		90.00	180.00	270.00																																										90.00								90.00				
H1994	001	0	1	02	01	H1994_001_0	11	4	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					401.99	33																																										33				33			33			
H1994	002	0	1	02	01	H1994_002_0	9	3	Non-Preferred Brand	1	4	100000	1	2	111100000010000000000001	30	60	90							1										30				31	14		90.00	180.00	270.00																																										90.00								90.00				
H1994	002	0	1	02	01	H1994_002_0	9	4	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					401.99	33																																										33				33			33			
H1994	002	0	1	02	01	H1994_002_0	9	2	Preferred Brand	1	4	000001	1	2	111100000010000000000001	30	60	90							1										30				31	14		45.00	90.00	135.00																																										45.00								45.00				
H1994	002	0	1	02	01	H1994_002_0	9	1	Generic	1	4	010000	1	2	011100000010000000000100	30	60	90							1										30		31					5.00	10.00	15.00																																										5.00					5.00							
H1994	003	0	1	02	01	H1994_003_0	9	4	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					401.99	33																																										33				33			33			
H1994	003	0	1	02	01	H1994_003_0	9	3	Non-Preferred Brand	1	4	100000	1	2	111100000010000000000001	30	60	90							1										30				31	14		90.00	180.00	270.00																																										90.00								90.00				
H1994	003	0	1	02	01	H1994_003_0	9	2	Preferred Brand	1	4	000001	1	2	111100000010000000000001	30	60	90							1										30				31	14		45.00	90.00	135.00																																										45.00								45.00				
H1994	003	0	1	02	01	H1994_003_0	9	1	Generic	1	4	010000	1	2	011100000010000000000100	30	60	90							1										30		31					5.00	10.00	15.00																																										5.00					5.00							
H1994	004	0	1	02	01	H1994_004_0	8	1	Generic	1	4	010000	1	2	011100000010000000000100	30	60	90							1										30		31					5.00	10.00	15.00																																										5.00					5.00							
H1994	004	0	1	02	01	H1994_004_0	8	2	Preferred Brand	1	4	000001	1	2	111100000010000000000001	30	60	90							1										30				31	14		45.00	90.00	135.00																																										45.00								45.00				
H1994	004	0	1	02	01	H1994_004_0	8	3	Non-Preferred Brand	1	4	100000	1	2	111100000010000000000001	30	60	90							1										30				31	14		90.00	180.00	270.00																																										90.00								90.00				
H1994	004	0	1	02	01	H1994_004_0	8	4	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					401.99	33																																										33				33			33			
H2001	001	0	1	04	01	H2001_001_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H2001	001	0	1	04	01	H2001_001_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					5.00		15.00																															10.00							15.00				5.00					5.00							
H2001	001	0	1	04	01	H2001_001_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H2001	001	0	1	04	01	H2001_001_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H2001	001	0	1	04	01	H2001_001_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					320.00	33		33																														33							33			33				33			33			
H2005	001	0	1	48	05	H2005_001_0	7	1	Preferred Generic	1	4	001000	3	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00							
H2005	001	0	1	48	05	H2005_001_0	7	2	Preferred Brand	1	4	000101	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00			0.00				
H2005	001	0	1	48	05	H2005_001_0	7	3	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00			0.00				
H2012	001	0	1	01	01	H2012_001_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					790.00	33																														33							33					33				33			33	2	3	
H2012	001	0	1	01	01	H2012_001_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00		2	3	
H2012	001	0	1	01	01	H2012_001_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H2012	001	0	1	01	01	H2012_001_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					674.00	33																														33							33					33				33			33			
H2012	001	0	1	01	01	H2012_001_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H2012	001	0	1	01	01	H2012_001_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		42.00		126.00																													42.00		116.00					42.00		126.00				42.00					42.00			42.00				
H2012	001	0	1	01	01	H2012_001_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H2012	001	0	1	01	01	H2012_001_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H2012	001	0	1	01	01	H2012_001_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		42.00		126.00																													42.00		116.00					42.00		126.00				42.00					42.00			42.00		2	2	
H2012	001	0	1	01	01	H2012_001_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00				
H2012	002	0	1	01	01	H2012_002_0	4	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					775.00	33																														33							33					33				33			33	2	3	
H2012	002	0	1	01	01	H2012_002_0	4	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H2012	002	0	1	01	01	H2012_002_0	4	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H2012	002	0	1	01	01	H2012_002_0	4	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H2012	002	0	1	01	01	H2012_002_0	4	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00		2	3	1
H2012	002	0	1	01	01	H2012_002_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					676.00	33																														33							33					33				33			33			
H2012	002	0	1	01	01	H2012_002_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H2012	002	0	1	01	01	H2012_002_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H2012	002	0	1	01	01	H2012_002_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H2012	002	0	1	01	01	H2012_002_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00				
H2012	003	0	1	01	01	H2012_003_0	8	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H2012	003	0	1	01	01	H2012_003_0	8	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H2012	003	0	1	01	01	H2012_003_0	8	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					964.00	33																														33							33					33				33			33	2	3	
H2012	003	0	1	01	01	H2012_003_0	8	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H2012	003	0	1	01	01	H2012_003_0	8	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H2012	003	0	1	01	01	H2012_003_0	8	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H2012	003	0	1	01	01	H2012_003_0	8	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	1
H2012	003	0	1	01	01	H2012_003_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					899.00	33																														33							33					33				33			33			
H2012	003	0	1	01	01	H2012_003_0	8	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H2012	003	0	1	01	01	H2012_003_0	8	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H2012	006	0	1	02	01	H2012_006_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					446.00	33																														33							33					33				33			33	2	3	
H2012	006	0	1	02	01	H2012_006_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00		2	3	
H2012	006	0	1	02	01	H2012_006_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H2012	006	0	1	02	01	H2012_006_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H2012	006	0	1	02	01	H2012_006_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00		2	3	1
H2012	006	0	1	02	01	H2012_006_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					391.00	33																														33							33					33				33			33			
H2012	006	0	1	02	01	H2012_006_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H2012	006	0	1	02	01	H2012_006_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H2012	006	0	1	02	01	H2012_006_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00				
H2012	006	0	1	02	01	H2012_006_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00				
H2012	007	0	1	01	01	H2012_007_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00				
H2012	007	0	1	01	01	H2012_007_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H2012	007	0	1	01	01	H2012_007_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H2012	007	0	1	01	01	H2012_007_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H2012	007	0	1	01	01	H2012_007_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1075.00	33																														33							33					33				33			33	2	3	
H2012	007	0	1	01	01	H2012_007_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00		2	3	1
H2012	007	0	1	01	01	H2012_007_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H2012	007	0	1	01	01	H2012_007_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H2012	007	0	1	01	01	H2012_007_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H2012	007	0	1	01	01	H2012_007_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					822.00	33																														33							33					33				33			33			
H2012	008	0	1	01	01	H2012_008_0	9	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H2012	008	0	1	01	01	H2012_008_0	9	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H2012	008	0	1	01	01	H2012_008_0	9	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H2012	008	0	1	01	01	H2012_008_0	9	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H2012	008	0	1	01	01	H2012_008_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1683.00	33																														33							33					33				33			33			
H2012	008	0	1	01	01	H2012_008_0	9	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H2012	008	0	1	01	01	H2012_008_0	9	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		1		
H2012	008	0	1	01	01	H2012_008_0	9	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H2012	008	0	1	01	01	H2012_008_0	9	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H2012	008	0	1	01	01	H2012_008_0	9	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1962.00	33																														33							33					33				33			33	2	3	
H2012	009	0	1	01	01	H2012_009_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H2012	009	0	1	01	01	H2012_009_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H2012	009	0	1	01	01	H2012_009_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H2012	009	0	1	01	01	H2012_009_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H2012	009	0	1	01	01	H2012_009_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					979.00	33																														33							33					33				33			33	2	3	
H2012	009	0	1	01	01	H2012_009_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H2012	009	0	1	01	01	H2012_009_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H2012	009	0	1	01	01	H2012_009_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H2012	009	0	1	01	01	H2012_009_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H2012	009	0	1	01	01	H2012_009_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					844.00	33																														33							33					33				33			33			
H2012	011	0	1	01	01	H2012_011_0	8	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H2012	011	0	1	01	01	H2012_011_0	8	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H2012	011	0	1	01	01	H2012_011_0	8	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H2012	011	0	1	01	01	H2012_011_0	8	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H2012	011	0	1	01	01	H2012_011_0	8	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					627.00	33																														33							33					33				33			33	2	3	
H2012	011	0	1	01	01	H2012_011_0	8	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H2012	011	0	1	01	01	H2012_011_0	8	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H2012	011	0	1	01	01	H2012_011_0	8	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H2012	011	0	1	01	01	H2012_011_0	8	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H2012	011	0	1	01	01	H2012_011_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					528.00	33																														33							33					33				33			33			
H2012	012	0	1	01	01	H2012_012_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H2012	012	0	1	01	01	H2012_012_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00		2	3	
H2012	012	0	1	01	01	H2012_012_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1442.00	33																														33							33					33				33			33	2	3	
H2012	012	0	1	01	01	H2012_012_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H2012	012	0	1	01	01	H2012_012_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H2012	012	0	1	01	01	H2012_012_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H2012	012	0	1	01	01	H2012_012_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00				
H2012	012	0	1	01	01	H2012_012_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1315.00	33																														33							33					33				33			33			
H2012	012	0	1	01	01	H2012_012_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	1
H2012	012	0	1	01	01	H2012_012_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00		2	2	
H2012	013	0	1	01	01	H2012_013_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					484.00	33																														33							33					33				33			33	2	3	
H2012	013	0	1	01	01	H2012_013_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H2012	013	0	1	01	01	H2012_013_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H2012	013	0	1	01	01	H2012_013_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H2012	013	0	1	01	01	H2012_013_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H2012	013	0	1	01	01	H2012_013_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H2012	013	0	1	01	01	H2012_013_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					451.00	33																														33							33					33				33			33			
H2012	013	0	1	01	01	H2012_013_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H2012	013	0	1	01	01	H2012_013_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H2012	013	0	1	01	01	H2012_013_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H2012	014	0	1	01	01	H2012_014_0	9	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		2.00		6.00																													0.00		0.00					2.00		6.00				2.00					2.00			2.00				
H2012	014	0	1	01	01	H2012_014_0	9	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H2012	014	0	1	01	01	H2012_014_0	9	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H2012	014	0	1	01	01	H2012_014_0	9	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H2012	014	0	1	01	01	H2012_014_0	9	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					997.00	33																														33							33					33				33			33	2	3	
H2012	014	0	1	01	01	H2012_014_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					873.00	33																														33							33					33				33			33			
H2012	014	0	1	01	01	H2012_014_0	9	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H2012	014	0	1	01	01	H2012_014_0	9	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H2012	014	0	1	01	01	H2012_014_0	9	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H2012	014	0	1	01	01	H2012_014_0	9	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		2.00		6.00																													0.00		0.00					2.00		6.00				2.00					2.00			2.00		2	3	1
H2012	015	0	1	01	01	H2012_015_0	8	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		88.00		264.00																													88.00		254.00					88.00		264.00				88.00					88.00			88.00		2	3	
H2012	015	0	1	01	01	H2012_015_0	8	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					991.00	33																														33							33					33				33			33	2	3	
H2012	015	0	1	01	01	H2012_015_0	8	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H2012	015	0	1	01	01	H2012_015_0	8	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00		2	2	
H2012	015	0	1	01	01	H2012_015_0	8	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00		2	3	1
H2012	015	0	1	01	01	H2012_015_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					789.00	33																														33							33					33				33			33			
H2012	015	0	1	01	01	H2012_015_0	8	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		88.00		264.00																													88.00		254.00					88.00		264.00				88.00					88.00			88.00				
H2012	015	0	1	01	01	H2012_015_0	8	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H2012	015	0	1	01	01	H2012_015_0	8	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00				
H2012	015	0	1	01	01	H2012_015_0	8	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00				
H2012	016	0	1	01	01	H2012_016_0	8	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H2012	016	0	1	01	01	H2012_016_0	8	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H2012	016	0	1	01	01	H2012_016_0	8	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H2012	016	0	1	01	01	H2012_016_0	8	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H2012	016	0	1	01	01	H2012_016_0	8	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					704.00	33																														33							33					33				33			33	2	3	
H2012	016	0	1	01	01	H2012_016_0	8	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H2012	016	0	1	01	01	H2012_016_0	8	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H2012	016	0	1	01	01	H2012_016_0	8	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H2012	016	0	1	01	01	H2012_016_0	8	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H2012	016	0	1	01	01	H2012_016_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					647.00	33																														33							33					33				33			33			
H2012	021	0	1	01	01	H2012_021_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H2012	021	0	1	01	01	H2012_021_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H2012	021	0	1	01	01	H2012_021_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H2012	021	0	1	01	01	H2012_021_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					729.00	33																														33							33					33				33			33	2	3	
H2012	021	0	1	01	01	H2012_021_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H2012	021	0	1	01	01	H2012_021_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					611.00	33																														33							33					33				33			33			
H2012	021	0	1	01	01	H2012_021_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H2012	021	0	1	01	01	H2012_021_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H2012	021	0	1	01	01	H2012_021_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H2012	021	0	1	01	01	H2012_021_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H2012	022	0	1	01	01	H2012_022_0	8	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H2012	022	0	1	01	01	H2012_022_0	8	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H2012	022	0	1	01	01	H2012_022_0	8	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H2012	022	0	1	01	01	H2012_022_0	8	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1190.00	33																														33							33					33				33			33			
H2012	022	0	1	01	01	H2012_022_0	8	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		39.00		117.00																													39.00		107.00					39.00		117.00				39.00					39.00			39.00				
H2012	022	0	1	01	01	H2012_022_0	8	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1494.00	33																														33							33					33				33			33	2	3	
H2012	022	0	1	01	01	H2012_022_0	8	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		39.00		117.00																													39.00		107.00					39.00		117.00				39.00					39.00			39.00		2	2	
H2012	022	0	1	01	01	H2012_022_0	8	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H2012	027	0	1	01	01	H2012_027_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					835.00	33																														33							33					33				33			33	2	3	
H2012	027	0	1	01	01	H2012_027_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H2012	027	0	1	01	01	H2012_027_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H2012	027	0	1	01	01	H2012_027_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H2012	027	0	1	01	01	H2012_027_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H2012	027	0	1	01	01	H2012_027_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					723.00	33																														33							33					33				33			33			
H2012	027	0	1	01	01	H2012_027_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H2012	027	0	1	01	01	H2012_027_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H2012	027	0	1	01	01	H2012_027_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H2012	027	0	1	01	01	H2012_027_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H2012	028	0	1	01	01	H2012_028_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H2012	028	0	1	01	01	H2012_028_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H2012	028	0	1	01	01	H2012_028_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H2012	028	0	1	01	01	H2012_028_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H2012	028	0	1	01	01	H2012_028_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					863.00	33																														33							33					33				33			33	2	3	
H2012	028	0	1	01	01	H2012_028_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H2012	028	0	1	01	01	H2012_028_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H2012	028	0	1	01	01	H2012_028_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H2012	028	0	1	01	01	H2012_028_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H2012	028	0	1	01	01	H2012_028_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					746.00	33																														33							33					33				33			33			
H2012	029	0	1	01	01	H2012_029_0	8	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H2012	029	0	1	01	01	H2012_029_0	8	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00				
H2012	029	0	1	01	01	H2012_029_0	8	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H2012	029	0	1	01	01	H2012_029_0	8	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H2012	029	0	1	01	01	H2012_029_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					758.00	33																														33							33					33				33			33			
H2012	029	0	1	01	01	H2012_029_0	8	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H2012	029	0	1	01	01	H2012_029_0	8	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00		1		
H2012	029	0	1	01	01	H2012_029_0	8	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H2012	029	0	1	01	01	H2012_029_0	8	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H2012	029	0	1	01	01	H2012_029_0	8	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					869.00	33																														33							33					33				33			33	2	3	
H2012	030	0	1	02	01	H2012_030_0	10	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H2012	030	0	1	02	01	H2012_030_0	10	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		39.00		117.00																													39.00		107.00					39.00		117.00				39.00					39.00			39.00				
H2012	030	0	1	02	01	H2012_030_0	10	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H2012	030	0	1	02	01	H2012_030_0	10	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H2012	030	0	1	02	01	H2012_030_0	10	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		39.00		117.00																													39.00		107.00					39.00		117.00				39.00					39.00			39.00		2	2	
H2012	030	0	1	02	01	H2012_030_0	10	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H2012	030	0	1	02	01	H2012_030_0	10	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					830.00	33																														33							33					33				33			33	2	3	
H2012	030	0	1	02	01	H2012_030_0	10	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					707.00	33																														33							33					33				33			33			
H2012	031	0	1	01	01	H2012_031_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H2012	031	0	1	01	01	H2012_031_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H2012	031	0	1	01	01	H2012_031_0	5	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H2012	031	0	1	01	01	H2012_031_0	5	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H2012	031	0	1	01	01	H2012_031_0	5	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					879.00	33																														33							33					33				33			33	2	3	
H2012	031	0	1	01	01	H2012_031_0	5	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					762.00	33																														33							33					33				33			33			
H2012	031	0	1	01	01	H2012_031_0	5	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H2012	031	0	1	01	01	H2012_031_0	5	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H2012	033	0	1	01	01	H2012_033_0	5	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H2012	033	0	1	01	01	H2012_033_0	5	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					817.00	33																														33							33					33				33			33	2	3	
H2012	033	0	1	01	01	H2012_033_0	5	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H2012	033	0	1	01	01	H2012_033_0	5	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H2012	033	0	1	01	01	H2012_033_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H2012	033	0	1	01	01	H2012_033_0	5	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					699.00	33																														33							33					33				33			33			
H2012	033	0	1	01	01	H2012_033_0	5	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H2012	033	0	1	01	01	H2012_033_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H2012	035	0	1	01	01	H2012_035_0	5	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					883.00	33																														33							33					33				33			33	2	3	
H2012	035	0	1	01	01	H2012_035_0	5	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H2012	035	0	1	01	01	H2012_035_0	5	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H2012	035	0	1	01	01	H2012_035_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H2012	035	0	1	01	01	H2012_035_0	5	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					772.00	33																														33							33					33				33			33			
H2012	035	0	1	01	01	H2012_035_0	5	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H2012	035	0	1	01	01	H2012_035_0	5	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H2012	035	0	1	01	01	H2012_035_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H2012	037	0	1	01	01	H2012_037_0	5	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					825.00	33																														33							33					33				33			33	2	3	
H2012	037	0	1	01	01	H2012_037_0	5	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H2012	037	0	1	01	01	H2012_037_0	5	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H2012	037	0	1	01	01	H2012_037_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H2012	037	0	1	01	01	H2012_037_0	5	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					708.00	33																														33							33					33				33			33			
H2012	037	0	1	01	01	H2012_037_0	5	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H2012	037	0	1	01	01	H2012_037_0	5	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H2012	037	0	1	01	01	H2012_037_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H2012	038	0	1	02	01	H2012_038_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H2012	038	0	1	02	01	H2012_038_0	7	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					771.00	33																														33							33					33				33			33			
H2012	038	0	1	02	01	H2012_038_0	7	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H2012	038	0	1	02	01	H2012_038_0	7	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H2012	038	0	1	02	01	H2012_038_0	7	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H2012	038	0	1	02	01	H2012_038_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H2012	038	0	1	02	01	H2012_038_0	7	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					881.00	33																														33							33					33				33			33	2	3	
H2012	038	0	1	02	01	H2012_038_0	7	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H2012	039	0	1	01	01	H2012_039_0	5	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					892.00	33																														33							33					33				33			33	2	3	
H2012	039	0	1	01	01	H2012_039_0	5	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H2012	039	0	1	01	01	H2012_039_0	5	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H2012	039	0	1	01	01	H2012_039_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H2012	039	0	1	01	01	H2012_039_0	5	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					777.00	33																														33							33					33				33			33			
H2012	039	0	1	01	01	H2012_039_0	5	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H2012	039	0	1	01	01	H2012_039_0	5	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H2012	039	0	1	01	01	H2012_039_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H2012	042	0	1	01	01	H2012_042_0	6	1	Preferred Generic	1	2	001010		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H2012	042	0	1	01	01	H2012_042_0	6	4	Specialty Tier	1	2	010010		1	110000000010000100100101	30													30			30			30		31		31	14					470.00	25																														25							25					25				25			25			
H2012	042	0	1	01	01	H2012_042_0	6	3	Non-Preferred Brand	1	2	100100		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		81.00		243.00																													81.00		233.00					81.00		243.00				81.00					81.00			81.00				
H2012	042	0	1	01	01	H2012_042_0	6	2	Preferred Brand	1	2	010001		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H2012	046	0	1	02	01	H2012_046_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					800.00	33																														33							33					33				33			33			
H2012	046	0	1	02	01	H2012_046_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H2012	046	0	1	02	01	H2012_046_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H2012	046	0	1	02	01	H2012_046_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H2012	046	0	1	02	01	H2012_046_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H2012	046	0	1	02	01	H2012_046_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H2012	046	0	1	02	01	H2012_046_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					921.00	33																														33							33					33				33			33	2	3	
H2012	046	0	1	02	01	H2012_046_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H2012	046	0	1	02	01	H2012_046_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H2012	046	0	1	02	01	H2012_046_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H2012	051	0	1	01	01	H2012_051_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H2012	051	0	1	01	01	H2012_051_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					724.00	33																														33							33					33				33			33			
H2012	051	0	1	01	01	H2012_051_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H2012	051	0	1	01	01	H2012_051_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00		2	3	1
H2012	051	0	1	01	01	H2012_051_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H2012	051	0	1	01	01	H2012_051_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H2012	051	0	1	01	01	H2012_051_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H2012	051	0	1	01	01	H2012_051_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H2012	051	0	1	01	01	H2012_051_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00				
H2012	051	0	1	01	01	H2012_051_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					838.00	33																														33							33					33				33			33	2	3	
H2012	053	0	1	01	01	H2012_053_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H2012	053	0	1	01	01	H2012_053_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H2012	053	0	1	01	01	H2012_053_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		42.00		126.00																													42.00		116.00					42.00		126.00				42.00					42.00			42.00				
H2012	053	0	1	01	01	H2012_053_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H2012	053	0	1	01	01	H2012_053_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					483.00	25																														25							25					25				25			25			
H2012	054	0	1	01	01	H2012_054_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					468.00	25																														25							25					25				25			25			
H2012	054	0	1	01	01	H2012_054_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H2012	054	0	1	01	01	H2012_054_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H2012	054	0	1	01	01	H2012_054_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		91.00		273.00																													91.00		263.00					91.00		273.00				91.00					91.00			91.00				
H2012	054	0	1	01	01	H2012_054_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H2012	055	0	1	01	01	H2012_055_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					878.00	33																														33							33					33				33			33	2	3	
H2012	055	0	1	01	01	H2012_055_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H2012	055	0	1	01	01	H2012_055_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H2012	055	0	1	01	01	H2012_055_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H2012	055	0	1	01	01	H2012_055_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H2012	055	0	1	01	01	H2012_055_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					767.00	33																														33							33					33				33			33			
H2012	055	0	1	01	01	H2012_055_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H2012	055	0	1	01	01	H2012_055_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H2012	055	0	1	01	01	H2012_055_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H2012	055	0	1	01	01	H2012_055_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H2012	056	0	1	01	01	H2012_056_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H2012	056	0	1	01	01	H2012_056_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H2012	056	0	1	01	01	H2012_056_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					852.00	33																														33							33					33				33			33	2	3	
H2012	056	0	1	01	01	H2012_056_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H2012	056	0	1	01	01	H2012_056_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H2012	056	0	1	01	01	H2012_056_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H2012	056	0	1	01	01	H2012_056_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H2012	056	0	1	01	01	H2012_056_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					741.00	33																														33							33					33				33			33			
H2012	056	0	1	01	01	H2012_056_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H2012	056	0	1	01	01	H2012_056_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H2012	059	0	1	01	01	H2012_059_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H2012	059	0	1	01	01	H2012_059_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00		2	3	
H2012	059	0	1	01	01	H2012_059_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	3	
H2012	059	0	1	01	01	H2012_059_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00		2	3	
H2012	059	0	1	01	01	H2012_059_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					883.00	33																														33							33					33				33			33	2	1	
H2012	059	0	1	01	01	H2012_059_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					765.00	33																														33							33					33				33			33			
H2012	059	0	1	01	01	H2012_059_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00				
H2012	059	0	1	01	01	H2012_059_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H2012	059	0	1	01	01	H2012_059_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H2012	059	0	1	01	01	H2012_059_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	1
H2012	060	0	1	01	01	H2012_060_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H2012	060	0	1	01	01	H2012_060_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H2012	060	0	1	01	01	H2012_060_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H2012	060	0	1	01	01	H2012_060_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H2012	060	0	1	01	01	H2012_060_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					837.00	33																														33							33					33				33			33	2	3	
H2012	060	0	1	01	01	H2012_060_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	1
H2012	060	0	1	01	01	H2012_060_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	2	
H2012	060	0	1	01	01	H2012_060_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	3	
H2012	060	0	1	01	01	H2012_060_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H2012	060	0	1	01	01	H2012_060_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					721.00	33																														33							33					33				33			33			
H2012	061	0	1	01	01	H2012_061_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H2012	061	0	1	01	01	H2012_061_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H2012	061	0	1	01	01	H2012_061_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H2012	061	0	1	01	01	H2012_061_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H2012	061	0	1	01	01	H2012_061_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					741.00	33																														33							33					33				33			33			
H2012	061	0	1	01	01	H2012_061_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	1
H2012	061	0	1	01	01	H2012_061_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	2	
H2012	061	0	1	01	01	H2012_061_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	3	
H2012	061	0	1	01	01	H2012_061_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H2012	061	0	1	01	01	H2012_061_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					855.00	33																														33							33					33				33			33	2	3	
H2012	062	0	1	01	01	H2012_062_0	6	1	Preferred Generic	1	2	001010		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H2012	062	0	1	01	01	H2012_062_0	6	2	Preferred Brand	1	2	010001		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		39.00		117.00																													39.00		107.00					39.00		117.00				39.00					39.00			39.00				
H2012	062	0	1	01	01	H2012_062_0	6	3	Non-Preferred Brand	1	2	100100		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H2012	062	0	1	01	01	H2012_062_0	6	4	Specialty Tier	1	2	010010		1	110000000010000100100101	30													30			30			30		31		31	14					467.00	25																														25							25					25				25			25			
H2012	063	0	1	01	01	H2012_063_0	7	4	Specialty Tier	1	2	010010		1	110000000010000100100101	30													30			30			30		31		31	14					484.00	25																														25							25					25				25			25			
H2012	063	0	1	01	01	H2012_063_0	7	3	Non-Preferred Brand	1	2	100100		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		88.00		264.00																													88.00		254.00					88.00		264.00				88.00					88.00			88.00				
H2012	063	0	1	01	01	H2012_063_0	7	1	Preferred Generic	1	2	001010		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H2012	063	0	1	01	01	H2012_063_0	7	2	Preferred Brand	1	2	010001		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H2012	064	0	1	01	01	H2012_064_0	7	3	Non-Preferred Brand	1	2	100100		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		84.00		252.00																													84.00		242.00					84.00		252.00				84.00					84.00			84.00				
H2012	064	0	1	01	01	H2012_064_0	7	2	Preferred Brand	1	2	010001		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H2012	064	0	1	01	01	H2012_064_0	7	1	Preferred Generic	1	2	001010		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H2012	064	0	1	01	01	H2012_064_0	7	4	Specialty Tier	1	2	010010		1	110000000010000100100101	30													30			30			30		31		31	14					477.00	25																														25							25					25				25			25			
H2012	070	0	1	01	01	H2012_070_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H2012	070	0	1	01	01	H2012_070_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H2012	070	0	1	01	01	H2012_070_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					454.00	25																														25							25					25				25			25			
H2012	070	0	1	01	01	H2012_070_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H2012	070	0	1	01	01	H2012_070_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H2012	075	0	1	01	01	H2012_075_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					475.00	25																														25							25					25				25			25			
H2012	075	0	1	01	01	H2012_075_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		70.00		210.00																													70.00		200.00					70.00		210.00				70.00					70.00			70.00				
H2012	075	0	1	01	01	H2012_075_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		35.00		105.00																													35.00		95.00					35.00		105.00				35.00					35.00			35.00				
H2012	075	0	1	01	01	H2012_075_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H2012	075	0	1	01	01	H2012_075_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H2012	076	0	1	01	01	H2012_076_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					506.00	25																														25							25					25				25			25			
H2012	076	0	1	01	01	H2012_076_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		50.00		150.00																													50.00		140.00					50.00		150.00				50.00					50.00			50.00				
H2012	076	0	1	01	01	H2012_076_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		25.00		75.00																													25.00		65.00					25.00		75.00				25.00					25.00			25.00				
H2012	076	0	1	01	01	H2012_076_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H2012	076	0	1	01	01	H2012_076_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H2012	080	0	1	01	01	H2012_080_0	8	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H2012	080	0	1	01	01	H2012_080_0	8	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		9.00		27.00																													0.00		0.00					9.00		27.00				9.00					9.00			9.00				
H2012	080	0	1	01	01	H2012_080_0	8	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		42.00		126.00																													42.00		116.00					42.00		126.00				42.00					42.00			42.00				
H2012	080	0	1	01	01	H2012_080_0	8	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00				
H2012	080	0	1	01	01	H2012_080_0	8	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00		2	3	
H2012	080	0	1	01	01	H2012_080_0	8	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	
H2012	080	0	1	01	01	H2012_080_0	8	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		9.00		27.00																													0.00		0.00					9.00		27.00				9.00					9.00			9.00		2	2	
H2012	080	0	1	01	01	H2012_080_0	8	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		42.00		126.00																													42.00		116.00					42.00		126.00				42.00					42.00			42.00		2	2	
H2012	080	0	1	01	01	H2012_080_0	8	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					2961.00	33																														33							33					33				33			33	2	3	
H2012	080	0	1	01	01	H2012_080_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					955.00	33																														33							33					33				33			33			
H2012	082	0	1	01	01	H2012_082_0	10	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					2300.00	33																														33							33					33				33			33	2	3	
H2012	082	0	1	01	01	H2012_082_0	10	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00		2	3	
H2012	082	0	1	01	01	H2012_082_0	10	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		42.00		126.00																													42.00		116.00					42.00		126.00				42.00					42.00			42.00		2	2	
H2012	082	0	1	01	01	H2012_082_0	10	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H2012	082	0	1	01	01	H2012_082_0	10	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H2012	082	0	1	01	01	H2012_082_0	10	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					774.00	33																														33							33					33				33			33			
H2012	082	0	1	01	01	H2012_082_0	10	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00				
H2012	082	0	1	01	01	H2012_082_0	10	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		42.00		126.00																													42.00		116.00					42.00		126.00				42.00					42.00			42.00				
H2012	082	0	1	01	01	H2012_082_0	10	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H2012	082	0	1	01	01	H2012_082_0	10	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H2029	001	0	1	04	01	H2029_001_0	9	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H2029	001	0	1	04	01	H2029_001_0	9	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00		2	3	1
H2029	001	0	1	04	01	H2029_001_0	9	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H2029	001	0	1	04	01	H2029_001_0	9	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					902.00	33																														33							33					33				33			33	2	3	
H2029	001	0	1	04	01	H2029_001_0	9	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H2029	001	0	1	04	01	H2029_001_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					794.00	33																														33							33					33				33			33			
H2029	001	0	1	04	01	H2029_001_0	9	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H2029	001	0	1	04	01	H2029_001_0	9	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H2029	001	0	1	04	01	H2029_001_0	9	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H2029	001	0	1	04	01	H2029_001_0	9	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00				
H2029	002	0	1	04	01	H2029_002_0	9	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H2029	002	0	1	04	01	H2029_002_0	9	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		30.00		90.00																													30.00		80.00					30.00		90.00				30.00					30.00			30.00		2	2	
H2029	002	0	1	04	01	H2029_002_0	9	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		68.00		204.00																													68.00		194.00					68.00		204.00				68.00					68.00			68.00		2	3	
H2029	002	0	1	04	01	H2029_002_0	9	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					905.00	33																														33							33					33				33			33	2	3	
H2029	002	0	1	04	01	H2029_002_0	9	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		3.00		9.00																													0.00		0.00					3.00		9.00				3.00					3.00			3.00				
H2029	002	0	1	04	01	H2029_002_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					832.00	33																														33							33					33				33			33			
H2029	002	0	1	04	01	H2029_002_0	9	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		68.00		204.00																													68.00		194.00					68.00		204.00				68.00					68.00			68.00				
H2029	002	0	1	04	01	H2029_002_0	9	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		30.00		90.00																													30.00		80.00					30.00		90.00				30.00					30.00			30.00				
H2029	002	0	1	04	01	H2029_002_0	9	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H2029	002	0	1	04	01	H2029_002_0	9	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		3.00		9.00																													0.00		0.00					3.00		9.00				3.00					3.00			3.00		2	3	1
H2038	002	0	1	09	04	H2038_002_0	6	1	Preferred Generic	1	3	001010		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H2038	002	0	1	09	04	H2038_002_0	6	2	Non-Preferred Generic	1	3	000101		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		11.00		33.00																													0.00		0.00					11.00		33.00				11.00					11.00			11.00				
H2038	002	0	1	09	04	H2038_002_0	6	5	Specialty Tier	1	3	010010		1	110000000010000100100101	30													30			30			30		31		31	14					611.00	26																														26							26					26				26			26			
H2038	002	0	1	09	04	H2038_002_0	6	4	Non-Preferred Brand	1	3	110000		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		75.00		225.00																													75.00		215.00					75.00		225.00				75.00					75.00			75.00				
H2038	002	0	1	09	04	H2038_002_0	6	3	Preferred Brand	1	3	000101		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		37.00		111.00																													37.00		101.00					37.00		111.00				37.00					37.00			37.00				
H2108	022	0	1	01	01	H2108_022_0	8	5	Specialty Tier	1	4	010010	1	1	111100000010001000000101	30	60	90							2			90							30		31		31	14					326.05	31	31	31																							31																	31				31			31			
H2108	022	0	1	01	01	H2108_022_0	8	4	Non-Preferred Brand	1	4	100100	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		80.00	160.00	240.00																								230.00																		80.00					80.00			80.00				
H2108	022	0	1	01	01	H2108_022_0	8	3	Preferred Brand	1	4	000001	1	2	111100000010001000000001	30	60	90							2			90							30				31	14		45.00	90.00	135.00																								125.00																		45.00								45.00				
H2108	022	0	1	01	01	H2108_022_0	8	2	Non-Preferred Generic	1	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		15.00	30.00	45.00																								36.00																		15.00					15.00			15.00				
H2108	022	0	1	01	01	H2108_022_0	8	1	Preferred Generic	1	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					8.00	16.00	24.00																								15.00																		8.00					8.00							
H2108	028	0	1	01	01	H2108_028_0	9	4	Non-Preferred Brand	1	4	100100	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		80.00	160.00	240.00																								230.00																		80.00					80.00			80.00				
H2108	028	0	1	01	01	H2108_028_0	9	1	Preferred Generic	1	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					4.00	8.00	12.00																								3.00																		4.00					4.00							
H2108	028	0	1	01	01	H2108_028_0	9	3	Preferred Brand	1	4	000001	1	2	111100000010001000000001	30	60	90							2			90							30				31	14		40.00	80.00	120.00																								110.00																		40.00								40.00				
H2108	028	0	1	01	01	H2108_028_0	9	2	Non-Preferred Generic	1	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		10.00	20.00	30.00																								21.00																		10.00					10.00			10.00				
H2108	028	0	1	01	01	H2108_028_0	9	5	Specialty Tier	1	4	010010	1	1	111100000010001000000101	30	60	90							2			90							30		31		31	14					330.36	33	33	33																							33																	33				33			33			
H2108	029	0	1	01	01	H2108_029_0	9	1	Preferred Generic	1	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					4.00	8.00	12.00																								3.00																		4.00					4.00							
H2108	029	0	1	01	01	H2108_029_0	9	3	Preferred Brand	1	4	000001	1	2	111100000010001000000001	30	60	90							2			90							30				31	14		40.00	80.00	120.00																								110.00																		40.00								40.00				
H2108	029	0	1	01	01	H2108_029_0	9	4	Non-Preferred Brand	1	4	100100	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		80.00	160.00	240.00																								230.00																		80.00					80.00			80.00				
H2108	029	0	1	01	01	H2108_029_0	9	5	Specialty Tier	1	4	010010	1	1	111100000010001000000101	30	60	90							2			90							30		31		31	14					296.10	33	33	33																							33																	33				33			33			
H2108	029	0	1	01	01	H2108_029_0	9	6	Select Diabetic Drugs	1	4	010010	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		5.00	10.00	15.00																								5.00																		5.00					5.00			5.00				
H2108	029	0	1	01	01	H2108_029_0	9	2	Non-Preferred Generic	1	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		10.00	20.00	30.00																								21.00																		10.00					10.00			10.00				
H2108	030	0	1	01	01	H2108_030_0	8	1	Preferred Generic	1	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					8.00	16.00	24.00																								15.00																		8.00					8.00							
H2108	030	0	1	01	01	H2108_030_0	8	2	Non-Preferred Generic	1	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		15.00	30.00	45.00																								36.00																		15.00					15.00			15.00				
H2108	030	0	1	01	01	H2108_030_0	8	3	Preferred Brand	1	4	000001	1	2	111100000010001000000001	30	60	90							2			90							30				31	14		45.00	90.00	135.00																								125.00																		45.00								45.00				
H2108	030	0	1	01	01	H2108_030_0	8	5	Specialty Tier	1	4	010010	1	1	111100000010001000000101	30	60	90							2			90							30		31		31	14					296.93	33	33	33																							33																	33				33			33			
H2108	030	0	1	01	01	H2108_030_0	8	6	Select Diabetic Drugs	1	4	010010	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		10.00	20.00	30.00																								20.00																		10.00					10.00			10.00				
H2108	030	0	1	01	01	H2108_030_0	8	4	Non-Preferred Brand	1	4	100100	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		80.00	160.00	240.00																								230.00																		80.00					80.00			80.00				
H2112	007	0	1	01	01	H2112_007_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H2112	007	0	1	01	01	H2112_007_0	6	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H2112	007	0	1	01	01	H2112_007_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H2112	007	0	1	01	01	H2112_007_0	6	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					7.00	14.00	21.00																													7.00	14.00	14.00					7.00	14.00	21.00					7.00				7.00							
H2112	007	0	1	01	01	H2112_007_0	6	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					252.34	33	33	33																												33	33	33					33	33	33				33			33			33			
H2112	014	0	1	01	01	H2112_014_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H2112	014	0	1	01	01	H2112_014_0	6	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					212.86	33	33	33																												33	33	33					33	33	33				33			33			33			
H2112	014	0	1	01	01	H2112_014_0	6	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H2112	014	0	1	01	01	H2112_014_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H2112	014	0	1	01	01	H2112_014_0	6	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					7.00	14.00	21.00																													7.00	14.00	14.00					7.00	14.00	21.00					7.00				7.00							
H2150	002	0	1	18	06	H2150_002_0	8	6	Vaccines	3	4	000001	1	2	100010010010000000000000				30			30													30					1										0.00								0.00																												0.00										1		
H2150	002	0	1	18	06	H2150_002_0	8	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				30		90	30		90	2						90			90	30		31													5.00		15.00						10.00		30.00															10.00							30.00				10.00					10.00							
H2150	002	0	1	18	06	H2150_002_0	8	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				30		90	30		90	2						90			90	30		31													10.00		30.00						33.00		99.00															20.00							99.00				33.00					33.00							
H2150	002	0	1	18	06	H2150_002_0	8	3	Preferred Brand	1	4	000001	1	2	100010110110000001001001				30		90	30		90	2						90			90	30				31	14										40.00		120.00						45.00		135.00															80.00							135.00				45.00								45.00				
H2150	002	0	1	18	06	H2150_002_0	8	4	Non-Preferred Brand	1	4	100000	1	2	100010110110000001001001				30		90	30		90	2						90			90	30				31	14										75.00		225.00						95.00		285.00															150.00							285.00				95.00								95.00				
H2150	002	0	1	18	06	H2150_002_0	8	5	Specialty Tier	1	4	100001	1	1	100010110110000101101001				30		90	30		90	2				30		90	30		90	30				31	14													499.00	25		25					499.00	25		25												25		25					25		25			25							25			
H2150	002	0	1	18	06	H2150_002_0	8	2	Non-Preferred Generic	3	4	000100	1	2	000010110110000001001100				30		90	30		90	2						90			90	30		31													10.00		30.00						33.00		99.00															20.00							99.00				33.00					33.00					1		
H2150	002	0	1	18	06	H2150_002_0	8	1	Preferred Generic	3	4	001000	1	2	000010110110000001001100				30		90	30		90	2						90			90	30		31													5.00		15.00						10.00		30.00															10.00							30.00				10.00					10.00					1		
H2150	002	0	1	18	06	H2150_002_0	8	6	Vaccines	1	4	000001	1	2	100010010010000000000000				30			30													30					1										0.00								0.00																												0.00												
H2150	009	0	1	18	06	H2150_009_0	8	5	Specialty Tier	1	4	100001	1	1	100010110110000101101001				30		90	30		90	2				30		90	30		90	30				31	14													507.00	25		25					507.00	25		25												25		25					25		25			25							25			
H2150	009	0	1	18	06	H2150_009_0	8	4	Non-Preferred Brand	1	4	100000	1	2	100010110110000001001001				30		90	30		90	2						90			90	30				31	14										90.00		270.00						95.00		285.00															180.00							285.00				95.00								95.00				
H2150	009	0	1	18	06	H2150_009_0	8	3	Preferred Brand	1	4	000001	1	2	100010110110000001001001				30		90	30		90	2						90			90	30				31	14										40.00		120.00						45.00		135.00															80.00							135.00				45.00								45.00				
H2150	009	0	1	18	06	H2150_009_0	8	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				30		90	30		90	2						90			90	30		31													25.00		75.00						33.00		99.00															50.00							99.00				33.00					33.00							
H2150	009	0	1	18	06	H2150_009_0	8	6	Vaccines	1	4	000001	1	2	100010010010000000000000				30			30													30					1										0.00								0.00																												0.00												
H2150	009	0	1	18	06	H2150_009_0	8	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				30		90	30		90	2						90			90	30		31													7.00		21.00						10.00		30.00															14.00							30.00				10.00					10.00							
H2150	029	0	2	18	06	H2150_029_0	7	4	Non-Preferred Brand	1	3	100000		2	100010110110000001001001				30		90	30		90	2						90			90	30				31	14										90.00		270.00						95.00		285.00															180.00							285.00				95.00								95.00				
H2150	029	0	2	18	06	H2150_029_0	7	5	Specialty Tier	1	3	100001		1	100010110110000101101001				30		90	30		90	2				30		90	30		90	30				31	14													608.00	25		25					608.00	25		25												25		25					25		25			25							25			
H2150	029	0	2	18	06	H2150_029_0	7	6	Vaccines	1	3	000001		2	100010010010000000000000				30			30													30					1										0.00								0.00																												0.00												
H2150	029	0	2	18	06	H2150_029_0	7	1	Preferred Generic	1	3	001000		2	000010110110000001001100				30		90	30		90	2						90			90	30		31													7.00		21.00						10.00		30.00															14.00							30.00				10.00					10.00							
H2150	029	0	2	18	06	H2150_029_0	7	2	Non-Preferred Generic	1	3	000100		2	000010110110000001001100				30		90	30		90	2						90			90	30		31													19.00		57.00						33.00		99.00															38.00							99.00				33.00					33.00							
H2150	029	0	2	18	06	H2150_029_0	7	3	Preferred Brand	1	3	000001		2	100010110110000001001001				30		90	30		90	2						90			90	30				31	14										40.00		120.00						45.00		135.00															80.00							135.00				45.00								45.00				
H2165	005	0	1	01	01	H2165_005_0	7	1	Preferred Generic	1	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					3.00	6.00	9.00																								0.00																		3.00					3.00							
H2165	005	0	1	01	01	H2165_005_0	7	2	Non-Preferred Generic	1	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		10.00	20.00	30.00																								21.00																		10.00					10.00			10.00				
H2165	005	0	1	01	01	H2165_005_0	7	3	Preferred Brand	1	4	000001	1	2	111100000010001000000001	30	60	90							2			90							30				31	14		45.00	90.00	135.00																								125.00																		45.00								45.00				
H2165	005	0	1	01	01	H2165_005_0	7	4	Non-Preferred Brand	1	4	100100	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		80.00	160.00	240.00																								230.00																		80.00					80.00			80.00				
H2165	005	0	1	01	01	H2165_005_0	7	2	Non-Preferred Generic	3	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		10.00	20.00	30.00																								21.00																		10.00					10.00			10.00		1		
H2165	005	0	1	01	01	H2165_005_0	7	1	Preferred Generic	3	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					3.00	6.00	9.00																								0.00																		3.00					3.00					1		
H2165	005	0	1	01	01	H2165_005_0	7	5	Specialty Tier	1	4	010010	1	1	111100000010001000000101	30	60	90							2			90							30		31		31	14					305.26	33	33	33																							33																	33				33			33			
H2165	011	0	1	02	01	H2165_011_0	6	2	Non-Preferred Generic	3	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		10.00	20.00	30.00																								21.00																		10.00					10.00			10.00		1		
H2165	011	0	1	02	01	H2165_011_0	6	4	Non-Preferred Brand	1	4	100100	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		80.00	160.00	240.00																								230.00																		80.00					80.00			80.00				
H2165	011	0	1	02	01	H2165_011_0	6	3	Preferred Brand	1	4	000001	1	2	111100000010001000000001	30	60	90							2			90							30				31	14		45.00	90.00	135.00																								125.00																		45.00								45.00				
H2165	011	0	1	02	01	H2165_011_0	6	1	Preferred Generic	3	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					3.00	6.00	9.00																								0.00																		3.00					3.00					1		
H2165	011	0	1	02	01	H2165_011_0	6	5	Specialty Tier	1	4	010010	1	1	111100000010001000000101	30	60	90							2			90							30		31		31	14					315.28	33	33	33																							33																	33				33			33			
H2165	011	0	1	02	01	H2165_011_0	6	2	Non-Preferred Generic	1	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		10.00	20.00	30.00																								21.00																		10.00					10.00			10.00				
H2165	011	0	1	02	01	H2165_011_0	6	1	Preferred Generic	1	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					3.00	6.00	9.00																								0.00																		3.00					3.00							
H2165	013	0	1	01	01	H2165_013_0	6	1	Preferred Generic	1	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					5.00	10.00	15.00																								6.00																		5.00					5.00							
H2165	013	0	1	01	01	H2165_013_0	6	2	Non-Preferred Generic	1	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		12.00	24.00	36.00																								27.00																		12.00					12.00			12.00				
H2165	013	0	1	01	01	H2165_013_0	6	3	Preferred Brand	1	4	000001	1	2	111100000010001000000001	30	60	90							2			90							30				31	14		45.00	90.00	135.00																								125.00																		45.00								45.00				
H2165	013	0	1	01	01	H2165_013_0	6	4	Non-Preferred Brand	1	4	100100	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		80.00	160.00	240.00																								230.00																		80.00					80.00			80.00				
H2165	013	0	1	01	01	H2165_013_0	6	2	Non-Preferred Generic	3	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		12.00	24.00	36.00																								27.00																		12.00					12.00			12.00		1		
H2165	013	0	1	01	01	H2165_013_0	6	1	Preferred Generic	3	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					5.00	10.00	15.00																								6.00																		5.00					5.00					1		
H2165	013	0	1	01	01	H2165_013_0	6	5	Specialty Tier	1	4	010010	1	1	111100000010001000000101	30	60	90							2			90							30		31		31	14					304.43	33	33	33																							33																	33				33			33			
H2165	015	0	1	02	01	H2165_015_0	6	2	Non-Preferred Generic	3	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		10.00	20.00	30.00																								21.00																		10.00					10.00			10.00		1		
H2165	015	0	1	02	01	H2165_015_0	6	1	Preferred Generic	3	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					3.00	6.00	9.00																								0.00																		3.00					3.00					1		
H2165	015	0	1	02	01	H2165_015_0	6	1	Preferred Generic	1	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					3.00	6.00	9.00																								0.00																		3.00					3.00							
H2165	015	0	1	02	01	H2165_015_0	6	4	Non-Preferred Brand	1	4	100100	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		80.00	160.00	240.00																								230.00																		80.00					80.00			80.00				
H2165	015	0	1	02	01	H2165_015_0	6	5	Specialty Tier	1	4	010010	1	1	111100000010001000000101	30	60	90							2			90							30		31		31	14					317.45	33	33	33																							33																	33				33			33			
H2165	015	0	1	02	01	H2165_015_0	6	2	Non-Preferred Generic	1	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		10.00	20.00	30.00																								21.00																		10.00					10.00			10.00				
H2165	015	0	1	02	01	H2165_015_0	6	3	Preferred Brand	1	4	000001	1	2	111100000010001000000001	30	60	90							2			90							30				31	14		45.00	90.00	135.00																								125.00																		45.00								45.00				
H2165	018	0	1	01	01	H2165_018_0	7	4	Non-Preferred Brand	1	4	100100	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		70.00	140.00	210.00																								200.00																		70.00					70.00			70.00				
H2165	018	0	1	01	01	H2165_018_0	7	5	Specialty Tier	1	4	010010	1	1	111100000010001000000101	30	60	90							2			90							30		31		31	14					292.23	33	33	33																							33																	33				33			33			
H2165	018	0	1	01	01	H2165_018_0	7	1	Preferred Generic	3	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					3.00	6.00	9.00																								0.00																		3.00					3.00					1		
H2165	018	0	1	01	01	H2165_018_0	7	2	Non-Preferred Generic	3	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		8.00	16.00	24.00																								15.00																		8.00					8.00			8.00		1		
H2165	018	0	1	01	01	H2165_018_0	7	3	Preferred Brand	1	4	000001	1	2	111100000010001000000001	30	60	90							2			90							30				31	14		35.00	70.00	105.00																								95.00																		35.00								35.00				
H2165	018	0	1	01	01	H2165_018_0	7	2	Non-Preferred Generic	1	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		8.00	16.00	24.00																								15.00																		8.00					8.00			8.00				
H2165	018	0	1	01	01	H2165_018_0	7	1	Preferred Generic	1	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					3.00	6.00	9.00																								0.00																		3.00					3.00							
H2174	008	0	1	01	01	H2174_008_0	6	4	Specialty Tier	1	4	000010	1	1	110000000010100000000001	31										31									31				31	14					488.78	33																							33																			33							33			
H2174	008	0	1	01	01	H2174_008_0	6	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	31	60	90							1	31	60	90							31				31	14		80.00	160.00	240.00																						80.00	160.00	240.00																		80.00								80.00				
H2174	008	0	1	01	01	H2174_008_0	6	1	Generic	1	4	010000	1	2	011100000010111000000100	31	60	90							1	31	60	90							31		31					8.00	16.00	24.00																						8.00	16.00	24.00																		8.00					8.00							
H2174	008	0	1	01	01	H2174_008_0	6	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	31	60	90							1	31	60	90							31				31	14		45.00	90.00	135.00																						45.00	90.00	135.00																		45.00								45.00				
H2182	001	0	1	02	01	H2182_001_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H2182	001	0	1	02	01	H2182_001_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H2182	001	0	1	02	01	H2182_001_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H2182	001	0	1	02	01	H2182_001_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H2182	001	0	1	02	01	H2182_001_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					568.00	33		33																														33							33			33				33			33			
H2224	001	0	1	01	01	H2224_001_0	5	1	Generic	1	4	010000	3	1	011100000010111000000110	30	60	90							2	30	60	90							30		31	14							5.30	25	25	25																					25	25	25																	25				25						
H2224	001	0	1	01	01	H2224_001_0	5	1	Generic	3	4	010000	3	1	011100000010111000000110	30	60	90							2	30	60	90							30		31	14							0.00	0	0	0																					0	0	0																	0				0				2		2
H2224	001	0	1	01	01	H2224_001_0	5	2	Brand	1	4	000010	1	1	111100000010111000000001	30	60	90							2	30	60	90							30				31	14					45.52	25	25	25																					25	25	25																	25							25			
H2230	002	0	1	04	01	H2230_002_0	12	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		31	14				6.00	12.00	18.00																						6.00	6.00	6.00																		6.00					6.00							
H2230	002	0	1	04	01	H2230_002_0	12	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		31	14				12.00	24.00	36.00																						12.00	24.00	24.00																		12.00					12.00							
H2230	002	0	1	04	01	H2230_002_0	12	3	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	90.00																		45.00								45.00				
H2230	002	0	1	04	01	H2230_002_0	12	4	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		90.00	180.00	270.00																						90.00	180.00	180.00																		90.00								90.00				
H2230	002	0	1	04	01	H2230_002_0	12	5	Specialty Tier	1	4	101101	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		31	14	31	14					539.26	30	30	30																					30	30	30																	30				30			30			
H2230	016	0	1	04	01	H2230_016_0	11	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		31	14				6.00	12.00	18.00																						6.00	6.00	6.00																		6.00					6.00							
H2230	016	0	1	04	01	H2230_016_0	11	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		31	14				12.00	24.00	36.00																						12.00	24.00	24.00																		12.00					12.00							
H2230	016	0	1	04	01	H2230_016_0	11	5	Specialty Tier	1	4	101101	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		31	14	31	14					509.95	27	27	27																					27	27	27																	27				27			27			
H2230	016	0	1	04	01	H2230_016_0	11	4	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		90.00	180.00	270.00																						90.00	180.00	180.00																		90.00								90.00				
H2230	016	0	1	04	01	H2230_016_0	11	3	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	90.00																		45.00								45.00				
H2237	001	0	1	01	01	H2237_001_0	5	1	Generic	1	3	010000		2	010000000010000000000110	30																			30		31	14				10.00																																												10.00				.32	10.00							
H2237	001	0	1	01	01	H2237_001_0	5	2	Brand	1	3	000010		2	110000000010000000000001	30																			30				31	14		48.00																																												48.00							1.54	48.00				
H2237	007	0	1	01	01	H2237_007_0	5	2	Brand	1	3	000010		2	110000000010000000000001	30																			30				31	14		47.00																																												47.00							1.51	47.00				
H2237	007	0	1	01	01	H2237_007_0	5	1	Generic	1	3	010000		2	010000000010000000000110	30																			30		31	14				8.00																																												8.00				.25	8.00							
H2241	001	0	1	01	01	H2241_001_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				0.00		0.00																								0.00																		0.00					0.00							
H2241	001	0	1	01	01	H2241_001_0	9	2	Preferred Brand	1	4	010001	1	2	110100000010001000000111	31		90							1			90							31		31	14	31	14		40.00		120.00																								80.00																		40.00					40.00			40.00				
H2241	001	0	1	01	01	H2241_001_0	9	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H2241	001	0	1	01	01	H2241_001_0	9	4	Specialty Tier	1	4	010010	1	1	110100000010001000000111	31		90							1			90							31		31	14	31	14					120.78	33		33																							33																	33				33			33			
H2241	001	0	1	01	01	H2241_001_0	9	3	Non-Preferred Brand	1	4	100100	1	2	110100000010001000000111	31		90							1			90							31		31	14	31	14		80.00		240.00																								160.00																		80.00					80.00			80.00				
H2256	001	1	1	01	01	H2256_001_1	11	2	Non-Preferred Generic	3	4	000100	1	2	011100000010111000000110	30	60	90							2	30	60	90							30		31	1				5.00	10.00	15.00																						4.00	8.00	12.00																		5.00					5.00					1		
H2256	001	1	1	01	01	H2256_001_1	11	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							2	30	60	90							30		31	1				3.00	6.00	9.00																						2.50	5.00	7.50																		3.00					3.00							
H2256	001	1	1	01	01	H2256_001_1	11	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							2	30	60	90							30		31	1				5.00	10.00	15.00																						4.00	8.00	12.00																		5.00					5.00							
H2256	001	1	1	01	01	H2256_001_1	11	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							2	30	60	90							30		31	1	31	1		30.00	60.00	90.00																						30.00	60.00	90.00																		30.00					30.00			30.00				
H2256	001	1	1	01	01	H2256_001_1	11	4	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							2	30	60	90							30				31	1		75.00	150.00	225.00																						75.00	150.00	225.00																		75.00								75.00				
H2256	001	1	1	01	01	H2256_001_1	11	5	Specialty Tier	1	4	010010	1	1	111100000010111000000111	30	60	90							2	30	60	90							30		31	1	31	1					584.00	33	33	33																					33	33	33																	33				33			33			
H2256	001	1	1	01	01	H2256_001_1	11	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	30	60	90							2	30	60	90							30		31	1				3.00	6.00	9.00																						2.50	5.00	7.50																		3.00					3.00					1		
H2256	001	2	1	01	01	H2256_001_2	10	2	Non-Preferred Generic	3	4	000100	1	2	011100000010111000000110	30	60	90							2	30	60	90							30		31	1				5.00	10.00	15.00																						4.00	8.00	12.00																		5.00					5.00					1		
H2256	001	2	1	01	01	H2256_001_2	10	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							2	30	60	90							30		31	1				3.00	6.00	9.00																						2.50	5.00	7.50																		3.00					3.00							
H2256	001	2	1	01	01	H2256_001_2	10	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							2	30	60	90							30		31	1				5.00	10.00	15.00																						4.00	8.00	12.00																		5.00					5.00							
H2256	001	2	1	01	01	H2256_001_2	10	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							2	30	60	90							30		31	1	31	1		30.00	60.00	90.00																						30.00	60.00	90.00																		30.00					30.00			30.00				
H2256	001	2	1	01	01	H2256_001_2	10	4	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							2	30	60	90							30				31	1		75.00	150.00	225.00																						75.00	150.00	225.00																		75.00								75.00				
H2256	001	2	1	01	01	H2256_001_2	10	5	Specialty Tier	1	4	010010	1	1	111100000010111000000111	30	60	90							2	30	60	90							30		31	1	31	1					584.00	33	33	33																					33	33	33																	33				33			33			
H2256	001	2	1	01	01	H2256_001_2	10	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	30	60	90							2	30	60	90							30		31	1				3.00	6.00	9.00																						2.50	5.00	7.50																		3.00					3.00					1		
H2256	001	6	1	01	01	H2256_001_6	10	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							2	30	60	90							30		31	1				3.00	6.00	9.00																						2.50	5.00	7.50																		3.00					3.00							
H2256	001	6	1	01	01	H2256_001_6	10	2	Non-Preferred Generic	3	4	000100	1	2	011100000010111000000110	30	60	90							2	30	60	90							30		31	1				5.00	10.00	15.00																						4.00	8.00	12.00																		5.00					5.00					1		
H2256	001	6	1	01	01	H2256_001_6	10	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	30	60	90							2	30	60	90							30		31	1				3.00	6.00	9.00																						2.50	5.00	7.50																		3.00					3.00					1		
H2256	001	6	1	01	01	H2256_001_6	10	5	Specialty Tier	1	4	010010	1	1	111100000010111000000111	30	60	90							2	30	60	90							30		31	1	31	1					584.00	33	33	33																					33	33	33																	33				33			33			
H2256	001	6	1	01	01	H2256_001_6	10	4	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							2	30	60	90							30				31	1		75.00	150.00	225.00																						75.00	150.00	225.00																		75.00								75.00				
H2256	001	6	1	01	01	H2256_001_6	10	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							2	30	60	90							30		31	1	31	1		30.00	60.00	90.00																						30.00	60.00	90.00																		30.00					30.00			30.00				
H2256	001	6	1	01	01	H2256_001_6	10	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							2	30	60	90							30		31	1				5.00	10.00	15.00																						4.00	8.00	12.00																		5.00					5.00							
H2256	015	1	1	01	01	H2256_015_1	9	4	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							2	30	60	90							30				31	1		93.00	186.00	279.00																						93.00	186.00	279.00																		93.00								93.00				
H2256	015	1	1	01	01	H2256_015_1	9	5	Specialty Tier	1	4	010010	1	1	111100000010111000000111	30	60	90							2	30	60	90							30		31	1	31	1					541.00	33	33	33																					33	33	33																	33				33			33			
H2256	015	1	1	01	01	H2256_015_1	9	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							2	30	60	90							30		31	1				10.00	20.00	30.00																						8.00	16.00	24.00																		10.00					10.00							
H2256	015	1	1	01	01	H2256_015_1	9	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							2	30	60	90							30		31	1				5.00	10.00	15.00																						4.00	8.00	12.00																		5.00					5.00							
H2256	015	1	1	01	01	H2256_015_1	9	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							2	30	60	90							30		31	1	31	1		33.00	66.00	99.00																						33.00	66.00	99.00																		33.00					33.00			33.00				
H2256	015	2	1	01	01	H2256_015_2	9	5	Specialty Tier	1	4	010010	1	1	111100000010111000000111	30	60	90							2	30	60	90							30		31	1	31	1					541.00	33	33	33																					33	33	33																	33				33			33			
H2256	015	2	1	01	01	H2256_015_2	9	4	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							2	30	60	90							30				31	1		93.00	186.00	279.00																						93.00	186.00	279.00																		93.00								93.00				
H2256	015	2	1	01	01	H2256_015_2	9	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							2	30	60	90							30		31	1				10.00	20.00	30.00																						8.00	16.00	24.00																		10.00					10.00							
H2256	015	2	1	01	01	H2256_015_2	9	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							2	30	60	90							30		31	1				5.00	10.00	15.00																						4.00	8.00	12.00																		5.00					5.00							
H2256	015	2	1	01	01	H2256_015_2	9	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							2	30	60	90							30		31	1	31	1		33.00	66.00	99.00																						33.00	66.00	99.00																		33.00					33.00			33.00				
H2256	015	6	1	01	01	H2256_015_6	9	5	Specialty Tier	1	4	010010	1	1	111100000010111000000111	30	60	90							2	30	60	90							30		31	1	31	1					541.00	33	33	33																					33	33	33																	33				33			33			
H2256	015	6	1	01	01	H2256_015_6	9	4	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							2	30	60	90							30				31	1		93.00	186.00	279.00																						93.00	186.00	279.00																		93.00								93.00				
H2256	015	6	1	01	01	H2256_015_6	9	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							2	30	60	90							30		31	1				10.00	20.00	30.00																						8.00	16.00	24.00																		10.00					10.00							
H2256	015	6	1	01	01	H2256_015_6	9	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							2	30	60	90							30		31	1	31	1		33.00	66.00	99.00																						33.00	66.00	99.00																		33.00					33.00			33.00				
H2256	015	6	1	01	01	H2256_015_6	9	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							2	30	60	90							30		31	1				5.00	10.00	15.00																						4.00	8.00	12.00																		5.00					5.00							
H2256	018	1	1	01	01	H2256_018_1	9	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							2	30	60	90							30		31	1				10.00	20.00	30.00																						8.00	16.00	24.00																		10.00					10.00							
H2256	018	1	1	01	01	H2256_018_1	9	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							2	30	60	90							30		31	1				5.00	10.00	15.00																						4.00	8.00	12.00																		5.00					5.00							
H2256	018	1	1	01	01	H2256_018_1	9	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							2	30	60	90							30		31	1	31	1		33.00	66.00	99.00																						33.00	66.00	99.00																		33.00					33.00			33.00				
H2256	018	1	1	01	01	H2256_018_1	9	5	Specialty Tier	1	4	010010	1	1	111100000010111000000111	30	60	90							2	30	60	90							30		31	1	31	1					1066.00	33	33	33																					33	33	33																	33				33			33			
H2256	018	1	1	01	01	H2256_018_1	9	4	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							2	30	60	90							30				31	1		93.00	186.00	279.00																						93.00	186.00	279.00																		93.00								93.00				
H2256	018	7	1	01	01	H2256_018_7	9	5	Specialty Tier	1	4	010010	1	1	111100000010111000000111	30	60	90							2	30	60	90							30		31	1	31	1					1066.00	33	33	33																					33	33	33																	33				33			33			
H2256	018	7	1	01	01	H2256_018_7	9	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							2	30	60	90							30		31	1	31	1		33.00	66.00	99.00																						33.00	66.00	99.00																		33.00					33.00			33.00				
H2256	018	7	1	01	01	H2256_018_7	9	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							2	30	60	90							30		31	1				5.00	10.00	15.00																						4.00	8.00	12.00																		5.00					5.00							
H2256	018	7	1	01	01	H2256_018_7	9	4	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							2	30	60	90							30				31	1		93.00	186.00	279.00																						93.00	186.00	279.00																		93.00								93.00				
H2256	018	7	1	01	01	H2256_018_7	9	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							2	30	60	90							30		31	1				10.00	20.00	30.00																						8.00	16.00	24.00																		10.00					10.00							
H2256	018	8	1	01	01	H2256_018_8	9	5	Specialty Tier	1	4	010010	1	1	111100000010111000000111	30	60	90							2	30	60	90							30		31	1	31	1					1066.00	33	33	33																					33	33	33																	33				33			33			
H2256	018	8	1	01	01	H2256_018_8	9	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							2	30	60	90							30		31	1	31	1		33.00	66.00	99.00																						33.00	66.00	99.00																		33.00					33.00			33.00				
H2256	018	8	1	01	01	H2256_018_8	9	4	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							2	30	60	90							30				31	1		93.00	186.00	279.00																						93.00	186.00	279.00																		93.00								93.00				
H2256	018	8	1	01	01	H2256_018_8	9	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							2	30	60	90							30		31	1				5.00	10.00	15.00																						4.00	8.00	12.00																		5.00					5.00							
H2256	018	8	1	01	01	H2256_018_8	9	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							2	30	60	90							30		31	1				10.00	20.00	30.00																						8.00	16.00	24.00																		10.00					10.00							
H2256	026	1	1	01	01	H2256_026_1	9	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							2	30	60	90							30		31	1				5.00	10.00	15.00																						4.00	8.00	12.00																		5.00					5.00							
H2256	026	1	1	01	01	H2256_026_1	9	5	Specialty Tier	1	4	010010	1	1	111100000010111000000111	30	60	90							2	30	60	90							30		31	1	31	1					920.00	33	33	33																					33	33	33																	33				33			33			
H2256	026	1	1	01	01	H2256_026_1	9	4	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							2	30	60	90							30				31	1		93.00	186.00	279.00																						93.00	186.00	279.00																		93.00								93.00				
H2256	026	1	1	01	01	H2256_026_1	9	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							2	30	60	90							30		31	1	31	1		33.00	66.00	99.00																						33.00	66.00	99.00																		33.00					33.00			33.00				
H2256	026	1	1	01	01	H2256_026_1	9	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							2	30	60	90							30		31	1				10.00	20.00	30.00																						8.00	16.00	24.00																		10.00					10.00							
H2256	026	2	1	01	01	H2256_026_2	9	5	Specialty Tier	1	4	010010	1	1	111100000010111000000111	30	60	90							2	30	60	90							30		31	1	31	1					920.00	33	33	33																					33	33	33																	33				33			33			
H2256	026	2	1	01	01	H2256_026_2	9	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							2	30	60	90							30		31	1				5.00	10.00	15.00																						4.00	8.00	12.00																		5.00					5.00							
H2256	026	2	1	01	01	H2256_026_2	9	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							2	30	60	90							30		31	1				10.00	20.00	30.00																						8.00	16.00	24.00																		10.00					10.00							
H2256	026	2	1	01	01	H2256_026_2	9	4	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							2	30	60	90							30				31	1		93.00	186.00	279.00																						93.00	186.00	279.00																		93.00								93.00				
H2256	026	2	1	01	01	H2256_026_2	9	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							2	30	60	90							30		31	1	31	1		33.00	66.00	99.00																						33.00	66.00	99.00																		33.00					33.00			33.00				
H2256	026	3	1	01	01	H2256_026_3	9	4	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							2	30	60	90							30				31	1		93.00	186.00	279.00																						93.00	186.00	279.00																		93.00								93.00				
H2256	026	3	1	01	01	H2256_026_3	9	5	Specialty Tier	1	4	010010	1	1	111100000010111000000111	30	60	90							2	30	60	90							30		31	1	31	1					920.00	33	33	33																					33	33	33																	33				33			33			
H2256	026	3	1	01	01	H2256_026_3	9	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							2	30	60	90							30		31	1				5.00	10.00	15.00																						4.00	8.00	12.00																		5.00					5.00							
H2256	026	3	1	01	01	H2256_026_3	9	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							2	30	60	90							30		31	1				10.00	20.00	30.00																						8.00	16.00	24.00																		10.00					10.00							
H2256	026	3	1	01	01	H2256_026_3	9	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							2	30	60	90							30		31	1	31	1		33.00	66.00	99.00																						33.00	66.00	99.00																		33.00					33.00			33.00				
H2256	028	0	1	01	01	H2256_028_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							2	30	60	90							30		31	1				10.00	20.00	30.00																						8.00	16.00	24.00																		10.00					10.00							
H2256	028	0	1	01	01	H2256_028_0	6	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							2	30	60	90							30		31	1				5.00	10.00	15.00																						4.00	8.00	12.00																		5.00					5.00							
H2256	028	0	1	01	01	H2256_028_0	6	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							2	30	60	90							30		31	1	31	1		45.00	90.00	135.00																						45.00	90.00	135.00																		45.00					45.00			45.00				
H2256	028	0	1	01	01	H2256_028_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							2	30	60	90							30				31	1		95.00	190.00	285.00																						95.00	190.00	285.00																		95.00								95.00				
H2256	028	0	1	01	01	H2256_028_0	6	5	Specialty Tier	1	4	010010	1	1	111100000010111000000111	30	60	90							2	30	60	90							30		31	1	31	1					870.00	33	33	33																					33	33	33																	33				33			33			
H2256	033	0	1	01	01	H2256_033_0	9	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							2	30	60	90							30		31	1				5.00	10.00	15.00																						4.00	8.00	12.00																		5.00					5.00							
H2256	033	0	1	01	01	H2256_033_0	9	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							2	30	60	90							30		31	1				5.00	10.00	15.00																						4.00	8.00	12.00																		5.00					5.00							
H2256	033	0	1	01	01	H2256_033_0	9	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							2	30	60	90							30		31	1	31	1		20.00	40.00	60.00																						20.00	40.00	60.00																		20.00					20.00			20.00				
H2256	033	0	1	01	01	H2256_033_0	9	5	Specialty Tier	1	4	010010	1	1	111100000010111000000111	30	60	90							2	30	60	90							30		31	1	31	1					693.00	33	33	33																					33	33	33																	33				33			33			
H2256	033	0	1	01	01	H2256_033_0	9	4	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							2	30	60	90							30				31	1		55.00	110.00	165.00																						55.00	110.00	165.00																		55.00								55.00				
H2256	034	0	1	01	01	H2256_034_0	8	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							2	30	60	90							30		31	1				5.00	10.00	15.00																						4.00	8.00	12.00																		5.00					5.00							
H2256	034	0	1	01	01	H2256_034_0	8	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							2	30	60	90							30		31	1				5.00	10.00	15.00																						4.00	8.00	12.00																		5.00					5.00							
H2256	034	0	1	01	01	H2256_034_0	8	4	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							2	30	60	90							30				31	1		55.00	110.00	165.00																						55.00	110.00	165.00																		55.00								55.00				
H2256	034	0	1	01	01	H2256_034_0	8	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							2	30	60	90							30		31	1	31	1		20.00	40.00	60.00																						20.00	40.00	60.00																		20.00					20.00			20.00				
H2256	034	0	1	01	01	H2256_034_0	8	5	Specialty Tier	1	4	010010	1	1	111100000010111000000111	30	60	90							2	30	60	90							30		31	1	31	1					1724.00	33	33	33																					33	33	33																	33				33			33			
H2256	036	0	1	01	01	H2256_036_0	7	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							2	30	60	90							30		31	1				5.00	10.00	15.00																						4.00	8.00	12.00																		5.00					5.00							
H2256	036	0	1	01	01	H2256_036_0	7	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							2	30	60	90							30		31	1	31	1		20.00	40.00	60.00																						20.00	40.00	60.00																		20.00					20.00			20.00				
H2256	036	0	1	01	01	H2256_036_0	7	4	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							2	30	60	90							30				31	1		55.00	110.00	165.00																						55.00	110.00	165.00																		55.00								55.00				
H2256	036	0	1	01	01	H2256_036_0	7	5	Specialty Tier	1	4	010010	1	1	111100000010111000000111	30	60	90							2	30	60	90							30		31	1	31	1					731.00	33	33	33																					33	33	33																	33				33			33			
H2256	036	0	1	01	01	H2256_036_0	7	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							2	30	60	90							30		31	1				5.00	10.00	15.00																						4.00	8.00	12.00																		5.00					5.00							
H2261	005	0	1	01	01	H2261_005_0	9	1	Preferred Generic	1	3	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		31	14				6.00	12.00	18.00																						6.00	6.00	6.00																		6.00					6.00							
H2261	005	0	1	01	01	H2261_005_0	9	2	Non-Preferred Generic	1	3	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		31	14				12.00	24.00	36.00																						12.00	24.00	24.00																		12.00					12.00							
H2261	005	0	1	01	01	H2261_005_0	9	3	Preferred Brand	1	3	000001		2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	90.00																		45.00								45.00				
H2261	005	0	1	01	01	H2261_005_0	9	4	Non-Preferred Brand	1	3	100000		2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		90.00	180.00	270.00																						90.00	180.00	180.00																		90.00								90.00				
H2261	005	0	1	01	01	H2261_005_0	9	5	Specialty Tier	1	3	101101		1	111100000010111000000111	30	60	90							1	30	60	90							30		31	14	31	14					554.67	30	30	30																					30	30	30																	30				30			30			
H2261	019	0	1	01	01	H2261_019_0	10	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		31	14				6.00	12.00	18.00																						6.00	6.00	6.00																		6.00					6.00							
H2261	019	0	1	01	01	H2261_019_0	10	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		31	14				12.00	24.00	36.00																						12.00	24.00	24.00																		12.00					12.00							
H2261	019	0	1	01	01	H2261_019_0	10	3	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	90.00																		45.00								45.00				
H2261	019	0	1	01	01	H2261_019_0	10	4	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		90.00	180.00	270.00																						90.00	180.00	180.00																		90.00								90.00				
H2261	019	0	1	01	01	H2261_019_0	10	5	Specialty Tier	1	4	101101	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		31	14	31	14					509.95	27	27	27																					27	27	27																	27				27			27			
H2312	004	0	1	01	01	H2312_004_0	5	5	Specialty Tier	1	4	000010	1	1	110100000010001000000001	30		90							1			90							30				31	14					1116.90	31		31																							31																	31							31			
H2312	004	0	1	01	01	H2312_004_0	5	4	Non-Preferred Brand	1	4	100000	1	1	110100000010001000000001	30		90							1			90							30				31	14					64.16	31		31																							31																	31							31			
H2312	004	0	1	01	01	H2312_004_0	5	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		45.00		112.50																								112.50																		45.00								45.00				
H2312	004	0	1	01	01	H2312_004_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					15.00		37.50																								37.50																		15.00					15.00							
H2312	004	0	1	01	01	H2312_004_0	5	1	Preferred Generic	1	4	001000	3	2	010100000010001000000100	30		90							1			90							30		31					2.00		5.00																								5.00																		2.00					2.00							
H2312	007	0	1	02	01	H2312_007_0	5	4	Non-Preferred Brand	1	4	100000	1	1	110100000010001000000001	30		90							1			90							30				31	14					68.46	32		32																							32																	32							32			
H2312	007	0	1	02	01	H2312_007_0	5	5	Specialty Tier	1	4	000010	1	1	110100000010001000000001	30		90							1			90							30				31	14					1018.66	32		32																							32																	32							32			
H2312	007	0	1	02	01	H2312_007_0	5	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		45.00		112.50																								112.50																		45.00								45.00				
H2312	007	0	1	02	01	H2312_007_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					15.00		37.50																								37.50																		15.00					15.00							
H2312	007	0	1	02	01	H2312_007_0	5	1	Preferred Generic	1	4	001000	3	2	010100000010001000000100	30		90							1			90							30		31					2.00		5.00																								5.00																		2.00					2.00							
H2312	009	0	1	01	01	H2312_009_0	6	1	Preferred Generic	3	4	001000	3	2	010100000010001000000100	30		90							1			90							30		31					2.00		5.00																								5.00																		2.00					2.00					1		
H2312	009	0	1	01	01	H2312_009_0	6	1	Preferred Generic	1	4	001000	3	2	010100000010001000000100	30		90							1			90							30		31					2.00		5.00																								5.00																		2.00					2.00							
H2312	009	0	1	01	01	H2312_009_0	6	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					10.00		25.00																								25.00																		10.00					10.00					1		
H2312	009	0	1	01	01	H2312_009_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					10.00		25.00																								25.00																		10.00					10.00							
H2312	009	0	1	01	01	H2312_009_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		40.00		100.00																								100.00																		40.00								40.00				
H2312	009	0	1	01	01	H2312_009_0	6	4	Non-Preferred Brand	1	4	100000	1	1	110100000010001000000001	30		90							1			90							30				31	14					72.67	31		31																							31																	31							31			
H2312	009	0	1	01	01	H2312_009_0	6	5	Specialty Tier	1	4	000010	1	1	110100000010001000000001	30		90							1			90							30				31	14					1228.72	31		31																							31																	31							31			
H2312	010	0	1	02	01	H2312_010_0	5	1	Preferred Generic	1	4	001000	3	2	010100000010001000000100	30		90							1			90							30		31					2.00		5.00																								5.00																		2.00					2.00							
H2312	010	0	1	02	01	H2312_010_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					10.00		25.00																								25.00																		10.00					10.00							
H2312	010	0	1	02	01	H2312_010_0	5	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		45.00		112.50																								112.50																		45.00								45.00				
H2312	010	0	1	02	01	H2312_010_0	5	4	Non-Preferred Brand	1	4	100000	1	1	110100000010001000000001	30		90							1			90							30				31	14					51.24	32		32																							32																	32							32			
H2312	010	0	1	02	01	H2312_010_0	5	5	Specialty Tier	1	4	000010	1	1	110100000010001000000001	30		90							1			90							30				31	14					1655.83	32		32																							32																	32							32			
H2312	010	0	1	02	01	H2312_010_0	5	1	Preferred Generic	3	4	001000	3	2	010100000010001000000100	30		90							1			90							30		31					2.00		5.00																								5.00																		2.00					2.00					1		
H2312	010	0	1	02	01	H2312_010_0	5	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					10.00		25.00																								25.00																		10.00					10.00					1		
H2312	012	0	1	02	01	H2312_012_0	6	1	Preferred Generic	1	4	001000	3	2	010100000010001000000100	30		90							1			90							30		31					6.00		15.00																								15.00																		6.00					6.00							
H2312	012	0	1	02	01	H2312_012_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					15.00		37.50																								37.50																		15.00					15.00							
H2312	012	0	1	02	01	H2312_012_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		45.00		112.50																								112.50																		45.00								45.00				
H2312	012	0	1	02	01	H2312_012_0	6	4	Non-Preferred Brand	1	4	100000	1	1	110100000010001000000001	30		90							1			90							30				31	14					63.04	33		33																							33																	33							33			
H2312	012	0	1	02	01	H2312_012_0	6	5	Specialty Tier	1	4	000010	1	1	110100000010001000000001	30		90							1			90							30				31	14					1092.68	33		33																							33																	33							33			
H2320	007	0	1	02	01	H2320_007_0	9	1	Generic	1	4	010000	1	2	010100000010101000000100	31		90							1	31		90							31		31					8.00		24.00																						8.00		20.00																		8.00					8.00							
H2320	007	0	1	02	01	H2320_007_0	9	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		35.00		105.00																						35.00		87.50																		35.00								35.00				
H2320	007	0	1	02	01	H2320_007_0	9	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		80.00		240.00																						80.00		200.00																		80.00								80.00				
H2320	007	0	1	02	01	H2320_007_0	9	4	Specialty Tier	1	4	010010	1	1	110000000010100000000101	31										31									31		31		31	14					398.32	33																							33																			33				33			33			
H2320	008	0	1	02	01	H2320_008_0	7	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		80.00		240.00																						80.00		200.00																		80.00								80.00				
H2320	008	0	1	02	01	H2320_008_0	7	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		35.00		105.00																						35.00		87.50																		35.00								35.00				
H2320	008	0	1	02	01	H2320_008_0	7	1	Generic	1	4	010000	1	2	010100000010101000000100	31		90							1	31		90							31		31					8.00		24.00																						8.00		20.00																		8.00					8.00							
H2320	008	0	1	02	01	H2320_008_0	7	4	Specialty Tier	1	4	010010	1	1	110000000010100000000101	31										31									31		31		31	14					398.32	33																							33																			33				33			33			
H2320	011	0	1	02	01	H2320_011_0	9	1	Generic	1	4	010000	1	2	010100000010101000000100	31		90							1	31		90							31		31					9.00		27.00																						9.00		22.50																		9.00					9.00							
H2320	011	0	1	02	01	H2320_011_0	9	4	Specialty Tier	1	4	010010	1	1	110000000010100000000101	31										31									31		31		31	14					398.32	33																							33																			33				33			33			
H2320	011	0	1	02	01	H2320_011_0	9	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		90.00		270.00																						90.00		225.00																		90.00								90.00				
H2320	011	0	1	02	01	H2320_011_0	9	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		40.00		120.00																						40.00		100.00																		40.00								40.00				
H2320	012	0	1	02	01	H2320_012_0	8	4	Specialty Tier	1	4	010010	1	1	110000000010100000000101	31										31									31		31		31	14					398.32	33																							33																			33				33			33			
H2320	012	0	1	02	01	H2320_012_0	8	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		90.00		270.00																						90.00		225.00																		90.00								90.00				
H2320	012	0	1	02	01	H2320_012_0	8	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		40.00		120.00																						40.00		100.00																		40.00								40.00				
H2320	012	0	1	02	01	H2320_012_0	8	1	Generic	1	4	010000	1	2	010100000010101000000100	31		90							1	31		90							31		31					9.00		27.00																						9.00		22.50																		9.00					9.00							
H2320	013	0	1	02	01	H2320_013_0	7	4	Specialty Tier	1	4	010010	1	1	110000000010100000000101	31										31									31		31		31	14					398.32	33																							33																			33				33			33			
H2320	013	0	1	02	01	H2320_013_0	7	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		80.00		240.00																						80.00		200.00																		80.00								80.00				
H2320	013	0	1	02	01	H2320_013_0	7	1	Generic	1	4	010000	1	2	010100000010101000000100	31		90							1	31		90							31		31					8.00		24.00																						8.00		20.00																		8.00					8.00							
H2320	013	0	1	02	01	H2320_013_0	7	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		35.00		105.00																						35.00		87.50																		35.00								35.00				
H2320	015	0	1	02	01	H2320_015_0	7	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		90.00		270.00																						90.00		225.00																		90.00								90.00				
H2320	015	0	1	02	01	H2320_015_0	7	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		40.00		120.00																						40.00		100.00																		40.00								40.00				
H2320	015	0	1	02	01	H2320_015_0	7	1	Generic	1	4	010000	1	2	010100000010101000000100	31		90							1	31		90							31		31					9.00		27.00																						9.00		22.50																		9.00					9.00							
H2320	015	0	1	02	01	H2320_015_0	7	4	Specialty Tier	1	4	010010	1	1	110000000010100000000101	31										31									31		31		31	14					398.32	33																							33																			33				33			33			
H2320	016	0	1	02	01	H2320_016_0	7	1	Generic	1	4	010000	1	2	010100000010101000000100	31		90							1	31		90							31		31					8.00		24.00																						8.00		20.00																		8.00					8.00							
H2320	016	0	1	02	01	H2320_016_0	7	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		35.00		105.00																						35.00		87.50																		35.00								35.00				
H2320	016	0	1	02	01	H2320_016_0	7	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		80.00		240.00																						80.00		200.00																		80.00								80.00				
H2320	016	0	1	02	01	H2320_016_0	7	4	Specialty Tier	1	4	010010	1	1	110000000010100000000101	31										31									31		31		31	14					398.32	33																							33																			33				33			33			
H2320	018	0	1	02	01	H2320_018_0	8	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		90.00		270.00																						90.00		225.00																		90.00								90.00				
H2320	018	0	1	02	01	H2320_018_0	8	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		40.00		120.00																						40.00		100.00																		40.00								40.00				
H2320	018	0	1	02	01	H2320_018_0	8	1	Generic	1	4	010000	1	2	010100000010101000000100	31		90							1	31		90							31		31					9.00		27.00																						9.00		22.50																		9.00					9.00							
H2320	018	0	1	02	01	H2320_018_0	8	4	Specialty Tier	1	4	010010	1	1	110000000010100000000101	31										31									31		31		31	14					398.32	33																							33																			33				33			33			
H2320	019	0	1	02	01	H2320_019_0	7	1	Generic	1	4	010000	1	2	010100000010101000000100	31		90							1	31		90							31		31					8.00		24.00																						8.00		20.00																		8.00					8.00							
H2320	019	0	1	02	01	H2320_019_0	7	4	Specialty Tier	1	4	010010	1	1	110000000010100000000101	31										31									31		31		31	14					398.32	33																							33																			33				33			33			
H2320	019	0	1	02	01	H2320_019_0	7	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		80.00		240.00																						80.00		200.00																		80.00								80.00				
H2320	019	0	1	02	01	H2320_019_0	7	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		35.00		105.00																						35.00		87.50																		35.00								35.00				
H2320	021	0	1	02	01	H2320_021_0	8	4	Specialty Tier	1	4	010010	1	1	110000000010100000000101	31										31									31		31		31	14					398.32	33																							33																			33				33			33			
H2320	021	0	1	02	01	H2320_021_0	8	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		90.00		270.00																						90.00		225.00																		90.00								90.00				
H2320	021	0	1	02	01	H2320_021_0	8	1	Generic	1	4	010000	1	2	010100000010101000000100	31		90							1	31		90							31		31					9.00		27.00																						9.00		22.50																		9.00					9.00							
H2320	021	0	1	02	01	H2320_021_0	8	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		40.00		120.00																						40.00		100.00																		40.00								40.00				
H2322	004	0	1	04	01	H2322_004_0	8	1	Preferred Generic	3	4	001000	3	2	010100000010001000000100	30		90							1			90							30		31					4.00		10.00																								10.00																		4.00					4.00					1		
H2322	004	0	1	04	01	H2322_004_0	8	5	Specialty Tier	1	4	000010	1	1	110100000010001000000001	30		90							1			90							30				31	14					1387.77	31		31																							31																	31							31			
H2322	004	0	1	04	01	H2322_004_0	8	4	Non-Preferred Brand	1	4	100000	1	1	110100000010001000000001	30		90							1			90							30				31	14					57.80	31		31																							31																	31							31			
H2322	004	0	1	04	01	H2322_004_0	8	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		40.00		100.00																								100.00																		40.00								40.00				
H2322	004	0	1	04	01	H2322_004_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					10.00		25.00																								25.00																		10.00					10.00							
H2322	004	0	1	04	01	H2322_004_0	8	1	Preferred Generic	1	4	001000	3	2	010100000010001000000100	30		90							1			90							30		31					4.00		10.00																								10.00																		4.00					4.00							
H2322	004	0	1	04	01	H2322_004_0	8	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					10.00		25.00																								25.00																		10.00					10.00					1		
H2322	008	0	1	04	01	H2322_008_0	9	1	Preferred Generic	1	4	001000	3	2	010100000010001000000100	30		90							1			90							30		31					2.00		5.00																								5.00																		2.00					2.00							
H2322	008	0	1	04	01	H2322_008_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					15.00		37.50																								37.50																		15.00					15.00							
H2322	008	0	1	04	01	H2322_008_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		45.00		112.50																								112.50																		45.00								45.00				
H2322	008	0	1	04	01	H2322_008_0	9	4	Non-Preferred Brand	1	4	100000	1	1	110100000010001000000001	30		90							1			90							30				31	14					63.04	33		33																							33																	33							33			
H2322	008	0	1	04	01	H2322_008_0	9	5	Specialty Tier	1	4	000010	1	1	110100000010001000000001	30		90							1			90							30				31	14					1092.68	33		33																							33																	33							33			
H2323	006	0	1	01	01	H2323_006_0	7	2	Preferred Brand	1	4	010001	1	2	110100000010001000000111	31		90							1			90							31		31	14	31	14		30.00		60.00																								60.00																		30.00					30.00			30.00				
H2323	006	0	1	01	01	H2323_006_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				5.00		10.00																								10.00																		5.00					5.00							
H2323	006	0	1	01	01	H2323_006_0	7	3	Non-Preferred Brand	1	4	110000	1	2	110100000010001000000111	31		90							1			90							31		31	14	31	14		65.00		130.00																								130.00																		65.00					65.00			65.00				
H2323	006	0	1	01	01	H2323_006_0	7	4	Specialty Tier	1	4	010010	1	1	110100000010100000000111	31		90							1	31									31		31	14	31	14					389.03	33		33																					33																			33				33			33			
H2323	007	0	1	01	01	H2323_007_0	10	4	Specialty Tier	1	4	010010	1	1	110100000010100000000111	31		90							1	31									31		31	14	31	14					491.63	33		33																					33																			33				33			33			
H2323	007	0	1	01	01	H2323_007_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				5.00		10.00																								10.00																		5.00					5.00							
H2323	007	0	1	01	01	H2323_007_0	10	2	Preferred Brand	1	4	010001	1	2	110100000010001000000111	31		90							1			90							31		31	14	31	14		30.00		60.00																								60.00																		30.00					30.00			30.00				
H2323	007	0	1	01	01	H2323_007_0	10	3	Non-Preferred Brand	1	4	110000	1	2	110100000010001000000111	31		90							1			90							31		31	14	31	14		65.00		130.00																								130.00																		65.00					65.00			65.00				
H2354	001	0	1	02	01	H2354_001_0	17	1	Generic	1	4	010000	1	2	010100000010101000000100	30		90							1	30		90							30		31					7.00		14.00																						7.00		14.00																		7.00					7.00							
H2354	001	0	1	02	01	H2354_001_0	17	4	Specialty Tier	1	4	010010	1	1	110100000010101000000101	30		90							1	30		90							30		31		31	14					25.00	25		25																					25		25																	25				25			25			
H2354	001	0	1	02	01	H2354_001_0	17	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							1	30		90							30				31	14		74.00		148.00																						74.00		148.00																		74.00								74.00				
H2354	001	0	1	02	01	H2354_001_0	17	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							1	30		90							30				31	14		39.00		78.00																						39.00		78.00																		39.00								39.00				
H2354	013	0	1	02	01	H2354_013_0	18	1	Generic	3	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					6.00	12.00	12.00																						6.00	12.00	12.00																		6.00					6.00					1		
H2354	013	0	1	02	01	H2354_013_0	18	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					6.00	12.00	12.00																						6.00	12.00	12.00																		6.00					6.00							
H2354	013	0	1	02	01	H2354_013_0	18	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							1	30		90							30				31	14		35.00		70.00																						35.00		70.00																		35.00								35.00				
H2354	013	0	1	02	01	H2354_013_0	18	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							1	30		90							30				31	14		70.00		140.00																						70.00		140.00																		70.00								70.00				
H2354	013	0	1	02	01	H2354_013_0	18	4	Specialty Tier	1	4	010010	1	1	110100000010101000000101	30		90							1	30		90							30		31		31	14					25.00	25		25																					25		25																	25				25			25			
H2354	015	0	1	02	01	H2354_015_0	20	1	Generic	1	2	010000		2	010100000010101000000100	30		90							1	30		90							30		31					6.00		12.00																						6.00		12.00																		6.00					6.00							
H2354	015	0	1	02	01	H2354_015_0	20	4	Specialty Tier	1	2	010010		1	110000000010000000000101	30																			30		31		31	14					25.00	25																																										25				25			25			
H2354	015	0	1	02	01	H2354_015_0	20	3	Non-Preferred Brand	1	2	100000		2	110100000010101000000001	30		90							1	30		90							30				31	14		64.00		128.00																						64.00		128.00																		64.00								64.00				
H2354	015	0	1	02	01	H2354_015_0	20	2	Preferred Brand	1	2	000001		2	110100000010101000000001	30		90							1	30		90							30				31	14		33.00		66.00																						33.00		66.00																		33.00								33.00				
H2425	002	0	1	02	01	H2425_002_0	11	4	Non-Preferred Brand	1	4	100000	1	1	111100000010001000000001	31	60	90							1			90							31				31	14					63.05	45	45	45																							45																	45							45			
H2425	002	0	1	02	01	H2425_002_0	11	1	Preferred Generic	1	4	001000	1	2	011100000010001000000110	31	60	90							1			90							31		31	14				8.00	16.00	24.00																								16.00																		8.00					8.00							
H2425	002	0	1	02	01	H2425_002_0	11	2	Non-Preferred Generic	1	4	000100	1	2	011100000010001000000110	31	60	90							1			90							31		31	14				15.00	30.00	45.00																								30.00																		15.00					15.00							
H2425	002	0	1	02	01	H2425_002_0	11	3	Preferred Brand	1	4	000001	1	2	111100000010001000000001	31	60	90							1			90							31				31	14		34.00	68.00	102.00																								68.00																		34.00								34.00				
H2450	001	0	1	18	06	H2450_001_0	6	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	31		90							1			90							31				31	14		74.00		222.00																								148.00																		74.00								74.00				
H2450	001	0	1	18	06	H2450_001_0	6	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	31		90							1			90							31				31	14		34.00		102.00																								68.00																		34.00								34.00				
H2450	001	0	1	18	06	H2450_001_0	6	1	Generic	1	4	010000	1	2	010100000010001000000100	31		90							1			90							31		31					10.00		30.00																								20.00																		10.00					10.00							
H2450	001	0	1	18	06	H2450_001_0	6	4	Specialty Tier	1	4	010010	1	1	110100000010001000000101	31		90							1			90							31		31		31	14					331.30	25		25																							25																	25				25			25			
H2450	002	0	1	18	06	H2450_002_0	4	4	Specialty Tier	1	4	010010	1	1	110100000010001000000101	31		90							1			90							31		31		31	14					283.53	25		25																							25																	25				25			25			
H2450	002	0	1	18	06	H2450_002_0	4	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	31		90							1			90							31				31	14		74.00		222.00																								148.00																		74.00								74.00				
H2450	002	0	1	18	06	H2450_002_0	4	1	Generic	1	4	010000	1	2	010100000010001000000100	31		90							1			90							31		31					10.00		30.00																								20.00																		10.00					10.00							
H2450	002	0	1	18	06	H2450_002_0	4	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	31		90							1			90							31				31	14		34.00		102.00																								68.00																		34.00								34.00				
H2450	005	0	1	18	06	H2450_005_0	5	4	Specialty Tier	1	4	010010	1	1	110100000010001000000101	31		90							1			90							31		31		31	14					286.18	25		25																							25																	25				25			25			
H2450	005	0	1	18	06	H2450_005_0	5	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	31		90							1			90							31				31	14		74.00		222.00																								148.00																		74.00								74.00				
H2450	005	0	1	18	06	H2450_005_0	5	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	31		90							1			90							31				31	14		34.00		102.00																								68.00																		34.00								34.00				
H2450	005	0	1	18	06	H2450_005_0	5	1	Generic	1	4	010000	1	2	010100000010001000000100	31		90							1			90							31		31					10.00		30.00																								20.00																		10.00					10.00							
H2450	005	0	1	18	06	H2450_005_0	5	1	Generic	3	4	010000	1	2	010100000010001000000100	31		90							1			90							31		31					10.00		30.00																								20.00																		10.00					10.00					1		
H2450	006	0	1	18	06	H2450_006_0	4	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	31		90							1			90							31				31	14		34.00		102.00																								68.00																		34.00								34.00				
H2450	006	0	1	18	06	H2450_006_0	4	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	31		90							1			90							31				31	14		74.00		222.00																								148.00																		74.00								74.00				
H2450	006	0	1	18	06	H2450_006_0	4	1	Generic	3	4	010000	1	2	010100000010001000000100	31		90							1			90							31		31					10.00		30.00																								20.00																		10.00					10.00					1		
H2450	006	0	1	18	06	H2450_006_0	4	1	Generic	1	4	010000	1	2	010100000010001000000100	31		90							1			90							31		31					10.00		30.00																								20.00																		10.00					10.00							
H2450	006	0	1	18	06	H2450_006_0	4	4	Specialty Tier	1	4	010010	1	1	110100000010001000000101	31		90							1			90							31		31		31	14					378.89	25		25																							25																	25				25			25			
H2450	023	0	1	18	06	H2450_023_0	5	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	31		90							1			90							31				31	14		74.00		222.00																								148.00																		74.00								74.00				
H2450	023	0	1	18	06	H2450_023_0	5	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	31		90							1			90							31				31	14		34.00		102.00																								68.00																		34.00								34.00				
H2450	023	0	1	18	06	H2450_023_0	5	1	Generic	1	4	010000	1	2	010100000010001000000100	31		90							1			90							31		31					10.00		30.00																								20.00																		10.00					10.00							
H2450	023	0	1	18	06	H2450_023_0	5	4	Specialty Tier	1	4	010010	1	1	110100000010001000000101	31		90							1			90							31		31		31	14					344.09	25		25																							25																	25				25			25			
H2450	028	0	1	18	06	H2450_028_0	5	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	31		90							1			90							31				31	14		34.00		102.00																								68.00																		34.00								34.00				
H2450	028	0	1	18	06	H2450_028_0	5	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	31		90							1			90							31				31	14		74.00		222.00																								148.00																		74.00								74.00				
H2450	028	0	1	18	06	H2450_028_0	5	4	Specialty Tier	1	4	010010	1	1	110100000010001000000101	31		90							1			90							31		31		31	14					360.53	25		25																							25																	25				25			25			
H2450	028	0	1	18	06	H2450_028_0	5	1	Generic	3	4	010000	1	2	010100000010001000000100	31		90							1			90							31		31					10.00		30.00																								20.00																		10.00					10.00					1		
H2450	028	0	1	18	06	H2450_028_0	5	1	Generic	1	4	010000	1	2	010100000010001000000100	31		90							1			90							31		31					10.00		30.00																								20.00																		10.00					10.00							
H2459	002	0	1	02	01	H2459_002_0	8	1	Preferred Generic	1	4	001000	1	2	010100000001001000000110	30		90							1			90								29	31	14				5.00		12.50																								10.00																			5.00				5.00							
H2459	002	0	1	02	01	H2459_002_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000001001000000110	30		90							1			90								29	31	14				10.00		25.00																								20.00																			10.00				10.00							
H2459	002	0	1	02	01	H2459_002_0	8	3	Preferred Brand	1	4	000001	1	2	110100000001001000000001	30		90							1			90								29			31	14		40.00		100.00																								80.00																			40.00							40.00				
H2459	002	0	1	02	01	H2459_002_0	8	4	Non-Preferred Brand	1	4	100000	1	2	110100000001001000000001	30		90							1			90								29			31	14		80.00		200.00																								160.00																			80.00							80.00				
H2459	002	0	1	02	01	H2459_002_0	8	2	Non-Preferred Generic	3	4	000100	1	2	010100000001001000000110	30		90							1			90								29	31	14				10.00		25.00																								20.00																			10.00				10.00					1		
H2459	002	0	1	02	01	H2459_002_0	8	1	Preferred Generic	3	4	001000	1	2	010100000001001000000110	30		90							1			90								29	31	14				5.00		12.50																								10.00																			5.00				5.00					1		
H2459	002	0	1	02	01	H2459_002_0	8	5	Specialty Tier	1	4	010010	1	1	110100000001001000000111	30		90							1			90								29	31	14	31	14					973.85	25		25																							25																		25			25			25			
H2459	013	0	1	02	01	H2459_013_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110100000001001000000001	30		90							1			90								29			31	14		80.00		200.00																								160.00																			80.00							80.00				
H2459	013	0	1	02	01	H2459_013_0	7	1	Preferred Generic	1	4	001000	1	2	010100000001001000000110	30		90							1			90								29	31	14				5.00		12.50																								10.00																			5.00				5.00							
H2459	013	0	1	02	01	H2459_013_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000001001000000110	30		90							1			90								29	31	14				10.00		25.00																								20.00																			10.00				10.00							
H2459	013	0	1	02	01	H2459_013_0	7	5	Specialty Tier	1	4	010010	1	1	110100000001001000000111	30		90							1			90								29	31	14	31	14					779.35	25		25																							25																		25			25			25			
H2459	013	0	1	02	01	H2459_013_0	7	3	Preferred Brand	1	4	000001	1	2	110100000001001000000001	30		90							1			90								29			31	14		40.00		100.00																								80.00																			40.00							40.00				
H2459	019	0	1	02	01	H2459_019_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000001001000000110	30		90							1			90								29	31	14				20.00		60.00																								40.00																			20.00				20.00							
H2459	019	0	1	02	01	H2459_019_0	9	3	Preferred Brand	1	4	000001	1	2	110100000001001000000001	30		90							1			90								29			31	14		45.00		135.00																								90.00																			45.00							45.00				
H2459	019	0	1	02	01	H2459_019_0	9	1	Preferred Generic	1	4	001000	1	2	010100000001001000000110	30		90							1			90								29	31	14				5.00		15.00																								10.00																			5.00				5.00							
H2459	019	0	1	02	01	H2459_019_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000001001000000001	30		90							1			90								29			31	14		90.00		270.00																								180.00																			90.00							90.00				
H2459	019	0	1	02	01	H2459_019_0	9	5	Specialty Tier	1	4	010010	1	1	110100000001001000000111	30		90							1			90								29	31	14	31	14					1028.74	33		33																							33																		33			33			33			
H2462	008	0	1	18	06	H2462_008_0	5	2	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							1				30		90	30		90	30				31	14		45.00		135.00																													45.00		90.00					45.00		135.00				45.00								45.00				
H2462	008	0	1	18	06	H2462_008_0	5	4	Specialty Tier	1	4	110001	1	1	110000000010000100100111	30													30			30			30		31	14	31	14					674.65	33																														33							33					33				33			33			
H2462	008	0	1	18	06	H2462_008_0	5	3	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							1				30		90	30		90	30				31	14		95.00		285.00																													95.00		190.00					95.00		285.00				95.00								95.00				
H2462	008	0	1	18	06	H2462_008_0	5	1	Generic	1	4	010001	1	2	110100000010000101101111	30		90							1				30		90	30		90	30		31	14	31	14		10.00		30.00																													10.00		20.00					10.00		30.00				10.00					10.00			10.00				
H2462	011	0	1	18	06	H2462_011_0	4	3	Non-Preferred Brand	1	3	100000		2	110100000010000101101001	30		90							1				30		90	30		90	30				31	14		95.00		285.00																													95.00		190.00					95.00		285.00				95.00								95.00				
H2462	011	0	1	18	06	H2462_011_0	4	2	Preferred Brand	1	3	000001		2	110100000010000101101001	30		90							1				30		90	30		90	30				31	14		45.00		135.00																													45.00		90.00					45.00		135.00				45.00								45.00				
H2462	011	0	1	18	06	H2462_011_0	4	1	Generic	1	3	010001		2	110100000010000101101111	30		90							1				30		90	30		90	30		31	14	31	14		10.00		30.00																													10.00		20.00					10.00		30.00				10.00					10.00			10.00				
H2462	011	0	1	18	06	H2462_011_0	4	4	Specialty Tier	1	3	110001		1	110000000010000100100111	30													30			30			30		31	14	31	14					1032.93	33																														33							33					33				33			33			
H2462	012	0	1	18	06	H2462_012_0	5	1	Generic	1	4	010001	1	2	110100000010000101101111	30		90							1				30		90	30		90	30		31	14	31	14		10.00		30.00																													10.00		20.00					10.00		30.00				10.00					10.00			10.00				
H2462	012	0	1	18	06	H2462_012_0	5	2	Preferred Brand	3	4	000001	1	1	110100000010000101101001	30		90							1				30		90	30		90	30				31	14					91.79	40		40																												40		40					45		45			40							40	1		
H2462	012	0	1	18	06	H2462_012_0	5	3	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							1				30		90	30		90	30				31	14		65.00		195.00																													65.00		130.00					65.00		195.00				65.00								65.00				
H2462	012	0	1	18	06	H2462_012_0	5	2	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							1				30		90	30		90	30				31	14		40.00		120.00																													40.00		80.00					40.00		120.00				40.00								40.00				
H2462	012	0	1	18	06	H2462_012_0	5	1	Generic	3	4	010001	1	2	110100000010000101101111	30		90							1				30		90	30		90	30		31	14	31	14		10.00		30.00																													10.00		20.00					10.00		30.00				10.00					10.00			10.00		1		
H2462	012	0	1	18	06	H2462_012_0	5	4	Specialty Tier	1	4	110001	1	1	110000000010000100100111	30													30			30			30		31	14	31	14					660.37	33																														33							33					33				33			33			
H2462	019	0	1	18	06	H2462_019_0	6	4	Specialty Tier	1	4	110001	1	1	110000000010000100100111	30													30			30			30		31	14	31	14					673.86	33																														33							33					33				33			33			
H2462	019	0	1	18	06	H2462_019_0	6	3	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							1				30		90	30		90	30				31	14		95.00		285.00																													95.00		190.00					95.00		285.00				95.00								95.00				
H2462	019	0	1	18	06	H2462_019_0	6	2	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							1				30		90	30		90	30				31	14		45.00		135.00																													45.00		90.00					45.00		135.00				45.00								45.00				
H2462	019	0	1	18	06	H2462_019_0	6	1	Generic	1	4	010001	1	2	110100000010000101101111	30		90							1				30		90	30		90	30		31	14	31	14		10.00		30.00																													10.00		20.00					10.00		30.00				10.00					10.00			10.00				
H2486	003	0	1	01	01	H2486_003_0	8	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H2486	003	0	1	01	01	H2486_003_0	8	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		44.00		132.00																													44.00		122.00					44.00		132.00				44.00					44.00			44.00		2	2	
H2486	003	0	1	01	01	H2486_003_0	8	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00		2	3	1
H2486	003	0	1	01	01	H2486_003_0	8	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1077.00	33																														33							33					33				33			33	2	3	
H2486	003	0	1	01	01	H2486_003_0	8	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00				
H2486	003	0	1	01	01	H2486_003_0	8	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		44.00		132.00																													44.00		122.00					44.00		132.00				44.00					44.00			44.00				
H2486	003	0	1	01	01	H2486_003_0	8	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H2486	003	0	1	01	01	H2486_003_0	8	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					872.00	33																														33							33					33				33			33			
H2491	002	0	1	02	01	H2491_002_0	7	4	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
H2491	002	0	1	02	01	H2491_002_0	7	3	Non-Preferred Brand	1	4	100000	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		68.00	136.00	204.00																													68.00	136.00	136.00							204.00				68.00								68.00				
H2491	002	0	1	02	01	H2491_002_0	7	1	Generic	1	4	010010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		4.00	8.00	12.00																													4.00	8.00	0.00							12.00				4.00					4.00			4.00				
H2491	002	0	1	02	01	H2491_002_0	7	2	Preferred Brand	1	4	000001	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		38.00	76.00	114.00																													38.00	76.00	76.00							114.00				38.00								38.00				
H2491	004	0	1	02	01	H2491_004_0	6	1	Preferred Generic	1	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
H2491	004	0	1	02	01	H2491_004_0	6	2	Preferred Brand	1	4	010001	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		45.00	90.00	135.00																													45.00	90.00	90.00							135.00				45.00					45.00			45.00				
H2491	004	0	1	02	01	H2491_004_0	6	3	Non-Preferred Brand	1	4	110000	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		95.00	190.00	285.00																													95.00	190.00	190.00							285.00				95.00					95.00			95.00				
H2491	004	0	1	02	01	H2491_004_0	6	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	31													31			31			31		31		31	14					707.00	25																														25							25					25				25			25			
H2542	001	0	1	04	01	H2542_001_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H2542	001	0	1	04	01	H2542_001_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					948.00	33																														33							33					33				33			33			
H2542	001	0	1	04	01	H2542_001_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H2542	001	0	1	04	01	H2542_001_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H2542	001	0	1	04	01	H2542_001_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H2542	001	0	1	04	01	H2542_001_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H2542	001	0	1	04	01	H2542_001_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H2542	001	0	1	04	01	H2542_001_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H2542	001	0	1	04	01	H2542_001_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H2542	001	0	1	04	01	H2542_001_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					999.00	33																														33							33					33				33			33	2	3	
H2542	002	0	1	04	01	H2542_002_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H2542	002	0	1	04	01	H2542_002_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H2542	002	0	1	04	01	H2542_002_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H2542	002	0	1	04	01	H2542_002_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H2542	002	0	1	04	01	H2542_002_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					972.00	33																														33							33					33				33			33	2	3	
H2542	002	0	1	04	01	H2542_002_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H2542	002	0	1	04	01	H2542_002_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H2542	002	0	1	04	01	H2542_002_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H2542	002	0	1	04	01	H2542_002_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H2542	002	0	1	04	01	H2542_002_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					827.00	33																														33							33					33				33			33			
H2542	003	0	1	04	01	H2542_003_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H2542	003	0	1	04	01	H2542_003_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H2542	003	0	1	04	01	H2542_003_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H2542	003	0	1	04	01	H2542_003_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					699.00	33																														33							33					33				33			33			
H2542	003	0	1	04	01	H2542_003_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H2542	003	0	1	04	01	H2542_003_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H2542	003	0	1	04	01	H2542_003_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H2542	003	0	1	04	01	H2542_003_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H2542	003	0	1	04	01	H2542_003_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H2542	003	0	1	04	01	H2542_003_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					789.00	33																														33							33					33				33			33	2	3	
H2542	004	0	1	04	01	H2542_004_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H2542	004	0	1	04	01	H2542_004_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H2542	004	0	1	04	01	H2542_004_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H2542	004	0	1	04	01	H2542_004_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					888.00	33																														33							33					33				33			33			
H2542	004	0	1	04	01	H2542_004_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H2542	004	0	1	04	01	H2542_004_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H2542	004	0	1	04	01	H2542_004_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H2542	004	0	1	04	01	H2542_004_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H2542	004	0	1	04	01	H2542_004_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H2542	004	0	1	04	01	H2542_004_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					984.00	33																														33							33					33				33			33	2	3	
H2542	005	0	1	04	01	H2542_005_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H2542	005	0	1	04	01	H2542_005_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H2542	005	0	1	04	01	H2542_005_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H2542	005	0	1	04	01	H2542_005_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H2542	005	0	1	04	01	H2542_005_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					906.00	33																														33							33					33				33			33	2	3	
H2542	005	0	1	04	01	H2542_005_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H2542	005	0	1	04	01	H2542_005_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H2542	005	0	1	04	01	H2542_005_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H2542	005	0	1	04	01	H2542_005_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H2542	005	0	1	04	01	H2542_005_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					807.00	33																														33							33					33				33			33			
H2542	006	0	1	04	01	H2542_006_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H2542	006	0	1	04	01	H2542_006_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H2542	006	0	1	04	01	H2542_006_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H2542	006	0	1	04	01	H2542_006_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					928.00	33																														33							33					33				33			33	2	3	
H2542	006	0	1	04	01	H2542_006_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H2542	006	0	1	04	01	H2542_006_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H2542	006	0	1	04	01	H2542_006_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H2542	006	0	1	04	01	H2542_006_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H2542	006	0	1	04	01	H2542_006_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					830.00	33																														33							33					33				33			33			
H2542	006	0	1	04	01	H2542_006_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H2542	007	0	1	04	01	H2542_007_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H2542	007	0	1	04	01	H2542_007_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H2542	007	0	1	04	01	H2542_007_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H2542	007	0	1	04	01	H2542_007_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H2542	007	0	1	04	01	H2542_007_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					913.00	33																														33							33					33				33			33	2	3	
H2542	007	0	1	04	01	H2542_007_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H2542	007	0	1	04	01	H2542_007_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H2542	007	0	1	04	01	H2542_007_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H2542	007	0	1	04	01	H2542_007_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H2542	007	0	1	04	01	H2542_007_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					816.00	33																														33							33					33				33			33			
H2593	001	0	1	01	01	H2593_001_0	8	4	Non-Preferred Brand	3	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00		2		
H2593	001	0	1	01	01	H2593_001_0	8	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								87.50																		35.00								35.00		2		
H2593	001	0	1	01	01	H2593_001_0	8	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00					1		
H2593	001	0	1	01	01	H2593_001_0	8	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H2593	001	0	1	01	01	H2593_001_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H2593	001	0	1	01	01	H2593_001_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H2593	001	0	1	01	01	H2593_001_0	8	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H2593	001	0	1	01	01	H2593_001_0	8	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								87.50																		35.00								35.00				
H2593	001	0	1	01	01	H2593_001_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H2593	001	0	1	01	01	H2593_001_0	8	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		10.00		30.00																								25.00																		10.00								10.00				
H2593	003	0	1	01	01	H2593_003_0	9	4	Non-Preferred Brand	3	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00		2		
H2593	003	0	1	01	01	H2593_003_0	9	6	Select Care Drugs	3	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00		1		
H2593	003	0	1	01	01	H2593_003_0	9	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								87.50																		35.00								35.00		2		
H2593	003	0	1	01	01	H2593_003_0	9	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00					1		
H2593	003	0	1	01	01	H2593_003_0	9	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H2593	003	0	1	01	01	H2593_003_0	9	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00				
H2593	003	0	1	01	01	H2593_003_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H2593	003	0	1	01	01	H2593_003_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H2593	003	0	1	01	01	H2593_003_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								87.50																		35.00								35.00				
H2593	003	0	1	01	01	H2593_003_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H2593	003	0	1	01	01	H2593_003_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H2593	005	0	1	01	01	H2593_005_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H2593	005	0	1	01	01	H2593_005_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H2593	005	0	1	01	01	H2593_005_0	10	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								87.50																		35.00								35.00				
H2593	005	0	1	01	01	H2593_005_0	10	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H2593	005	0	1	01	01	H2593_005_0	10	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H2593	005	0	1	01	01	H2593_005_0	10	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								87.50																		35.00								35.00		2		
H2593	005	0	1	01	01	H2593_005_0	10	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H2593	005	0	1	01	01	H2593_005_0	10	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00					1		
H2593	005	0	1	01	01	H2593_005_0	10	6	Select Care Drugs	3	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00		1		
H2593	005	0	1	01	01	H2593_005_0	10	4	Non-Preferred Brand	3	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00		2		
H2593	005	0	1	01	01	H2593_005_0	10	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00				
H2593	006	0	1	01	01	H2593_006_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H2593	006	0	1	01	01	H2593_006_0	9	6	Select Care Drugs	3	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00		1		
H2593	006	0	1	01	01	H2593_006_0	9	4	Non-Preferred Brand	3	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00		2		
H2593	006	0	1	01	01	H2593_006_0	9	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								87.50																		35.00								35.00		2		
H2593	006	0	1	01	01	H2593_006_0	9	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00					1		
H2593	006	0	1	01	01	H2593_006_0	9	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H2593	006	0	1	01	01	H2593_006_0	9	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00				
H2593	006	0	1	01	01	H2593_006_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H2593	006	0	1	01	01	H2593_006_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								87.50																		35.00								35.00				
H2593	006	0	1	01	01	H2593_006_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H2593	006	0	1	01	01	H2593_006_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H2593	007	0	1	01	01	H2593_007_0	8	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H2593	007	0	1	01	01	H2593_007_0	8	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								87.50																		35.00								35.00		2		
H2593	007	0	1	01	01	H2593_007_0	8	4	Non-Preferred Brand	3	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00		2		
H2593	007	0	1	01	01	H2593_007_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H2593	007	0	1	01	01	H2593_007_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H2593	007	0	1	01	01	H2593_007_0	8	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								87.50																		35.00								35.00				
H2593	007	0	1	01	01	H2593_007_0	8	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00					1		
H2593	007	0	1	01	01	H2593_007_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H2593	007	0	1	01	01	H2593_007_0	8	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		10.00		30.00																								25.00																		10.00								10.00				
H2593	007	0	1	01	01	H2593_007_0	8	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H2593	009	0	1	01	01	H2593_009_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H2593	009	0	1	01	01	H2593_009_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H2593	009	0	1	01	01	H2593_009_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H2593	009	0	1	01	01	H2593_009_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								87.50																		35.00								35.00				
H2593	009	0	1	01	01	H2593_009_0	9	6	Select Care Drugs	3	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00		1		
H2593	009	0	1	01	01	H2593_009_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H2593	009	0	1	01	01	H2593_009_0	9	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								87.50																		35.00								35.00		2		
H2593	009	0	1	01	01	H2593_009_0	9	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00					1		
H2593	009	0	1	01	01	H2593_009_0	9	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H2593	009	0	1	01	01	H2593_009_0	9	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00				
H2593	009	0	1	01	01	H2593_009_0	9	4	Non-Preferred Brand	3	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00		2		
H2593	011	0	1	01	01	H2593_011_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H2593	011	0	1	01	01	H2593_011_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H2593	011	0	1	01	01	H2593_011_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								87.50																		35.00								35.00				
H2593	011	0	1	01	01	H2593_011_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H2593	011	0	1	01	01	H2593_011_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H2593	011	0	1	01	01	H2593_011_0	9	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00				
H2593	011	0	1	01	01	H2593_011_0	9	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H2593	011	0	1	01	01	H2593_011_0	9	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00					1		
H2593	011	0	1	01	01	H2593_011_0	9	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								87.50																		35.00								35.00		2		
H2593	011	0	1	01	01	H2593_011_0	9	4	Non-Preferred Brand	3	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00		2		
H2593	011	0	1	01	01	H2593_011_0	9	6	Select Care Drugs	3	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00		1		
H2593	013	0	1	01	01	H2593_013_0	9	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								87.50																		35.00								35.00		2		
H2593	013	0	1	01	01	H2593_013_0	9	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00					1		
H2593	013	0	1	01	01	H2593_013_0	9	4	Non-Preferred Brand	3	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00		2		
H2593	013	0	1	01	01	H2593_013_0	9	6	Select Care Drugs	3	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00		1		
H2593	013	0	1	01	01	H2593_013_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H2593	013	0	1	01	01	H2593_013_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H2593	013	0	1	01	01	H2593_013_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								87.50																		35.00								35.00				
H2593	013	0	1	01	01	H2593_013_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H2593	013	0	1	01	01	H2593_013_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H2593	013	0	1	01	01	H2593_013_0	9	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00				
H2593	013	0	1	01	01	H2593_013_0	9	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H2593	014	0	1	01	01	H2593_014_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H2593	014	0	1	01	01	H2593_014_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								87.50																		35.00								35.00				
H2593	014	0	1	01	01	H2593_014_0	9	6	Select Care Drugs	3	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00		1		
H2593	014	0	1	01	01	H2593_014_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H2593	014	0	1	01	01	H2593_014_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H2593	014	0	1	01	01	H2593_014_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H2593	014	0	1	01	01	H2593_014_0	9	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H2593	014	0	1	01	01	H2593_014_0	9	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00					1		
H2593	014	0	1	01	01	H2593_014_0	9	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								87.50																		35.00								35.00		2		
H2593	014	0	1	01	01	H2593_014_0	9	4	Non-Preferred Brand	3	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00		2		
H2593	014	0	1	01	01	H2593_014_0	9	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00				
H2593	015	0	1	01	01	H2593_015_0	9	4	Non-Preferred Brand	3	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00		2		
H2593	015	0	1	01	01	H2593_015_0	9	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								87.50																		35.00								35.00		2		
H2593	015	0	1	01	01	H2593_015_0	9	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00					1		
H2593	015	0	1	01	01	H2593_015_0	9	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H2593	015	0	1	01	01	H2593_015_0	9	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00				
H2593	015	0	1	01	01	H2593_015_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H2593	015	0	1	01	01	H2593_015_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H2593	015	0	1	01	01	H2593_015_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								87.50																		35.00								35.00				
H2593	015	0	1	01	01	H2593_015_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H2593	015	0	1	01	01	H2593_015_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H2593	015	0	1	01	01	H2593_015_0	9	6	Select Care Drugs	3	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00		1		
H2593	016	0	1	01	01	H2593_016_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H2593	016	0	1	01	01	H2593_016_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					10.00		30.00																								25.00																		10.00					10.00							
H2593	016	0	1	01	01	H2593_016_0	8	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		45.00		135.00																								112.50																		45.00								45.00				
H2593	016	0	1	01	01	H2593_016_0	8	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		95.00		285.00																								237.50																		95.00								95.00				
H2593	016	0	1	01	01	H2593_016_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H2593	016	0	1	01	01	H2593_016_0	8	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		10.00		30.00																								25.00																		10.00								10.00				
H2593	018	0	1	01	01	H2593_018_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H2593	018	0	1	01	01	H2593_018_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					10.00		30.00																								25.00																		10.00					10.00							
H2593	018	0	1	01	01	H2593_018_0	8	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		45.00		135.00																								112.50																		45.00								45.00				
H2593	018	0	1	01	01	H2593_018_0	8	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		95.00		285.00																								237.50																		95.00								95.00				
H2593	018	0	1	01	01	H2593_018_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H2593	018	0	1	01	01	H2593_018_0	8	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		10.00		30.00																								25.00																		10.00								10.00				
H2610	005	0	1	01	01	H2610_005_0	11	1	Preferred Generic	1	4	001000	1	2	000011111101111000000100				31	62	93	31	62	93	1	31	62	93								14	34													0.00	0.00	0.00						2.00	4.00	6.00						2.00	4.00	6.00																			2.00				2.00							
H2610	005	0	1	01	01	H2610_005_0	11	2	Non-Preferred Generic	1	4	000100	1	2	000011111101111000000100				31	62	93	31	62	93	1	31	62	93								14	34													0.00	0.00	0.00						5.00	10.00	15.00						5.00	10.00	15.00																			5.00				5.00							
H2610	005	0	1	01	01	H2610_005_0	11	3	Preferred Brand	1	4	000001	1	2	100011111101111000000001				31	62	93	31	62	93	1	31	62	93								14			34	14										29.00	58.00	87.00						34.00	68.00	102.00						34.00	68.00	102.00																			34.00							34.00				
H2610	005	0	1	01	01	H2610_005_0	11	4	Non-Preferred Brand	1	4	100000	1	2	100011111101111000000001				31	62	93	31	62	93	1	31	62	93								14			34	14										59.00	118.00	177.00						69.00	138.00	207.00						69.00	138.00	207.00																			69.00							69.00				
H2610	005	0	1	01	01	H2610_005_0	11	5	Specialty Tier	1	4	100100	1	1	100010010001100000000101				31			31				31										14	34		34	14													188.96	33							188.96	33							33																				33			33			33			
H2610	006	0	1	01	01	H2610_006_0	11	5	Specialty Tier	1	4	100100	1	1	100010010001100000000101				31			31				31										14	34		34	14													247.20	33							247.20	33							33																				33			33			33			
H2610	006	0	1	01	01	H2610_006_0	11	1	Preferred Generic	3	4	001000	1	2	000011111101111000000100				31	62	93	31	62	93	1	31	62	93								14	34													0.00	0.00	0.00						2.00	4.00	6.00						2.00	4.00	6.00																			2.00				2.00					1		
H2610	006	0	1	01	01	H2610_006_0	11	2	Non-Preferred Generic	3	4	000100	1	2	000011111101111000000100				31	62	93	31	62	93	1	31	62	93								14	34													0.00	0.00	0.00						5.00	10.00	15.00						5.00	10.00	15.00																			5.00				5.00					1		
H2610	006	0	1	01	01	H2610_006_0	11	3	Preferred Brand	1	4	000001	1	2	100011111101111000000001				31	62	93	31	62	93	1	31	62	93								14			34	14										24.00	48.00	72.00						29.00	58.00	87.00						29.00	58.00	87.00																			29.00							29.00				
H2610	006	0	1	01	01	H2610_006_0	11	4	Non-Preferred Brand	1	4	100000	1	2	100011111101111000000001				31	62	93	31	62	93	1	31	62	93								14			34	14										49.00	98.00	147.00						59.00	118.00	177.00						59.00	118.00	177.00																			59.00							59.00				
H2610	006	0	1	01	01	H2610_006_0	11	2	Non-Preferred Generic	1	4	000100	1	2	000011111101111000000100				31	62	93	31	62	93	1	31	62	93								14	34													0.00	0.00	0.00						5.00	10.00	15.00						5.00	10.00	15.00																			5.00				5.00							
H2610	006	0	1	01	01	H2610_006_0	11	1	Preferred Generic	1	4	001000	1	2	000011111101111000000100				31	62	93	31	62	93	1	31	62	93								14	34													0.00	0.00	0.00						2.00	4.00	6.00						2.00	4.00	6.00																			2.00				2.00							
H2610	011	0	1	01	01	H2610_011_0	10	5	Specialty Tier	1	4	100100	1	1	100010010001100000000101				31			31				31										14	34		34	14													228.24	33							228.24	33							33																				33			33			33			
H2610	011	0	1	01	01	H2610_011_0	10	4	Non-Preferred Brand	1	4	100000	1	2	100011111101111000000001				31	62	93	31	62	93	1	31	62	93								14			34	14										75.00	150.00	225.00						85.00	170.00	255.00						85.00	170.00	255.00																			85.00							85.00				
H2610	011	0	1	01	01	H2610_011_0	10	3	Preferred Brand	1	4	000001	1	2	100011111101111000000001				31	62	93	31	62	93	1	31	62	93								14			34	14										37.00	74.00	111.00						42.00	84.00	126.00						42.00	84.00	126.00																			42.00							42.00				
H2610	011	0	1	01	01	H2610_011_0	10	1	Preferred Generic	1	4	001000	1	2	000011111101111000000100				31	62	93	31	62	93	1	31	62	93								14	34													0.00	0.00	0.00						2.00	4.00	6.00						2.00	4.00	6.00																			2.00				2.00							
H2610	011	0	1	01	01	H2610_011_0	10	2	Non-Preferred Generic	1	4	000100	1	2	000011111101111000000100				31	62	93	31	62	93	1	31	62	93								14	34													0.00	0.00	0.00						6.00	12.00	18.00						6.00	12.00	18.00																			6.00				6.00							
H2611	001	0	1	04	01	H2611_001_0	7	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													634.48	33							634.48	33																										33				33			33			
H2611	001	0	1	04	01	H2611_001_0	7	3	Non-Preferred Brand	1	4	100100	1	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										80.00		240.00						95.00		285.00						80.00		240.00																		95.00					95.00			95.00				
H2611	001	0	1	04	01	H2611_001_0	7	2	Preferred Brand	1	4	000001	1	2	100010110110101000000001				30		90	30		90	2	30		90							30				31	14										40.00		120.00						45.00		135.00						40.00		120.00																		45.00								45.00				
H2611	001	0	1	04	01	H2611_001_0	7	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													5.00		15.00						8.00		24.00						5.00		15.00																		8.00					8.00							
H2611	008	0	1	04	01	H2611_008_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					5.00		15.00																						5.00		15.00																		5.00					5.00							
H2611	008	0	1	04	01	H2611_008_0	8	4	Specialty Tier	1	4	010001	1	1	110000000010000000000101	30																			30		31		31	14					593.31	33																																										33				33			33			
H2611	008	0	1	04	01	H2611_008_0	8	3	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		80.00		240.00																						80.00		240.00																		80.00					80.00			80.00				
H2611	008	0	1	04	01	H2611_008_0	8	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		40.00		120.00																						40.00		120.00																		40.00								40.00				
H2611	018	0	1	04	01	H2611_018_0	9	3	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		80.00		240.00																						80.00		240.00																		80.00					80.00			80.00				
H2611	018	0	1	04	01	H2611_018_0	9	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		45.00		135.00																						45.00		135.00																		45.00								45.00				
H2611	018	0	1	04	01	H2611_018_0	9	4	Specialty Tier	1	4	010001	1	1	110000000010000000000101	30																			30		31		31	14					607.58	33																																										33				33			33			
H2611	018	0	1	04	01	H2611_018_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					5.00		15.00																						5.00		15.00																		5.00					5.00							
H2649	004	0	1	01	01	H2649_004_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H2649	004	0	1	01	01	H2649_004_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					963.00	33																														33							33					33				33			33	2	3	
H2649	004	0	1	01	01	H2649_004_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H2649	004	0	1	01	01	H2649_004_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H2649	004	0	1	01	01	H2649_004_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H2649	004	0	1	01	01	H2649_004_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H2649	004	0	1	01	01	H2649_004_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H2649	004	0	1	01	01	H2649_004_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H2649	004	0	1	01	01	H2649_004_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					799.00	33																														33							33					33				33			33			
H2649	004	0	1	01	01	H2649_004_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H2649	020	0	1	01	01	H2649_020_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H2649	020	0	1	01	01	H2649_020_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					490.00	33																														33							33					33				33			33			
H2649	020	0	1	01	01	H2649_020_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H2649	020	0	1	01	01	H2649_020_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H2649	020	0	1	01	01	H2649_020_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					799.00	33																														33							33					33				33			33	2	3	
H2649	020	0	1	01	01	H2649_020_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H2649	020	0	1	01	01	H2649_020_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H2649	020	0	1	01	01	H2649_020_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H2649	020	0	1	01	01	H2649_020_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H2649	020	0	1	01	01	H2649_020_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H2649	021	0	1	02	01	H2649_021_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H2649	021	0	1	02	01	H2649_021_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H2649	021	0	1	02	01	H2649_021_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H2649	021	0	1	02	01	H2649_021_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H2649	021	0	1	02	01	H2649_021_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					758.00	33																														33							33					33				33			33			
H2649	021	0	1	02	01	H2649_021_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H2649	021	0	1	02	01	H2649_021_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H2649	021	0	1	02	01	H2649_021_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H2649	021	0	1	02	01	H2649_021_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H2649	021	0	1	02	01	H2649_021_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					866.00	33																														33							33					33				33			33	2	3	
H2649	022	0	1	01	01	H2649_022_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					904.00	33																														33							33					33				33			33	2	3	
H2649	022	0	1	01	01	H2649_022_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00		2	3	1
H2649	022	0	1	01	01	H2649_022_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		41.00		123.00																													41.00		113.00					41.00		123.00				41.00					41.00			41.00		2	2	
H2649	022	0	1	01	01	H2649_022_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H2649	022	0	1	01	01	H2649_022_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		82.00		246.00																													82.00		236.00					82.00		246.00				82.00					82.00			82.00		2	3	
H2649	022	0	1	01	01	H2649_022_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					794.00	33																														33							33					33				33			33			
H2649	022	0	1	01	01	H2649_022_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		82.00		246.00																													82.00		236.00					82.00		246.00				82.00					82.00			82.00				
H2649	022	0	1	01	01	H2649_022_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		41.00		123.00																													41.00		113.00					41.00		123.00				41.00					41.00			41.00				
H2649	022	0	1	01	01	H2649_022_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H2649	022	0	1	01	01	H2649_022_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H2649	023	0	1	01	01	H2649_023_0	4	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					875.00	33																														33							33					33				33			33	2	3	
H2649	023	0	1	01	01	H2649_023_0	4	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H2649	023	0	1	01	01	H2649_023_0	4	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H2649	023	0	1	01	01	H2649_023_0	4	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H2649	023	0	1	01	01	H2649_023_0	4	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H2649	023	0	1	01	01	H2649_023_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H2649	023	0	1	01	01	H2649_023_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H2649	023	0	1	01	01	H2649_023_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H2649	023	0	1	01	01	H2649_023_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					764.00	33																														33							33					33				33			33			
H2649	023	0	1	01	01	H2649_023_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H2649	024	0	1	01	01	H2649_024_0	5	5	Specialty Tier	3	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													718.00	25							729.00	25														25							25					25				25			25	2	3	
H2649	024	0	1	01	01	H2649_024_0	5	4	Non-Preferred Brand	3	4	110000	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													114.00	30		30					116.00	50		50												30		30					50		50			50				50			50	2	3	
H2649	024	0	1	01	01	H2649_024_0	5	3	Preferred Brand	3	4	000101	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													22.00	18		18					31.00	25		25												18		18					25		25			25				25			25	2	2	
H2649	024	0	1	01	01	H2649_024_0	5	2	Non-Preferred Generic	3	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										3.00		9.00						10.00		30.00													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	3	
H2649	024	0	1	01	01	H2649_024_0	5	4	Non-Preferred Brand	1	4	110000	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													89.00	30		30					91.00	50		50												30		30					50		50			50				50			50			
H2649	024	0	1	01	01	H2649_024_0	5	5	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													617.00	25							626.00	25														25							25					25				25			25			
H2649	024	0	1	01	01	H2649_024_0	5	3	Preferred Brand	1	4	000101	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													16.00	18		18					23.00	25		25												18		18					25		25			25				25			25			
H2649	024	0	1	01	01	H2649_024_0	5	2	Non-Preferred Generic	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										3.00		9.00						10.00		30.00													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H2649	024	0	1	01	01	H2649_024_0	5	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										1.00		3.00						8.00		24.00													0.00		0.00					8.00		24.00				8.00					8.00			8.00				
H2649	025	0	1	01	01	H2649_025_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					786.00	33																														33							33					33				33			33			
H2649	025	0	1	01	01	H2649_025_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00				
H2649	025	0	1	01	01	H2649_025_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H2649	025	0	1	01	01	H2649_025_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		11.00		33.00																													0.00		0.00					11.00		33.00				11.00					11.00			11.00				
H2649	025	0	1	01	01	H2649_025_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					798.00	33																														33							33					33				33			33	2	3	
H2649	025	0	1	01	01	H2649_025_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H2649	025	0	1	01	01	H2649_025_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		11.00		33.00																													0.00		0.00					11.00		33.00				11.00					11.00			11.00		2	2	
H2649	025	0	1	01	01	H2649_025_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	3	
H2649	025	0	1	01	01	H2649_025_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00		2	3	
H2649	025	0	1	01	01	H2649_025_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H2654	004	0	1	01	01	H2654_004_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					451.00	33		33																														33							33			33				33			33			
H2654	004	0	1	01	01	H2654_004_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		92.00		276.00																															266.00							276.00				92.00					92.00			92.00				
H2654	004	0	1	01	01	H2654_004_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		44.00		132.00																															122.00							132.00				44.00					44.00			44.00				
H2654	004	0	1	01	01	H2654_004_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															0.00							18.00				6.00					6.00							
H2654	004	0	1	01	01	H2654_004_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00							
H2654	010	0	1	02	01	H2654_010_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H2654	010	0	1	02	01	H2654_010_0	8	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					566.00	33		33																														33							33			33				33			33			
H2654	010	0	1	02	01	H2654_010_0	8	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H2654	010	0	1	02	01	H2654_010_0	8	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H2654	010	0	1	02	01	H2654_010_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H2654	013	0	1	02	01	H2654_013_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															0.00							18.00				6.00					6.00							
H2654	013	0	1	02	01	H2654_013_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H2654	013	0	1	02	01	H2654_013_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H2654	013	0	1	02	01	H2654_013_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00							
H2654	013	0	1	02	01	H2654_013_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					593.00	33		33																														33							33			33				33			33			
H2654	029	0	1	02	01	H2654_029_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H2654	029	0	1	02	01	H2654_029_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H2654	029	0	1	02	01	H2654_029_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					460.00	33		33																														33							33			33				33			33			
H2654	029	0	1	02	01	H2654_029_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															0.00							18.00				6.00					6.00							
H2654	029	0	1	02	01	H2654_029_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00							
H2663	002	0	1	02	01	H2663_002_0	10	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													7.00		21.00						10.00		30.00						7.00		21.00																		10.00					10.00							
H2663	002	0	1	02	01	H2663_002_0	10	2	Preferred Brand	1	4	000001	1	2	100010110110101000000001				30		90	30		90	2	30		90							30				31	14										40.00		120.00						45.00		135.00						40.00		120.00																		45.00								45.00				
H2663	002	0	1	02	01	H2663_002_0	10	3	Non-Preferred Brand	1	4	100100	1	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										80.00		240.00						95.00		285.00						80.00		240.00																		95.00					95.00			95.00				
H2663	002	0	1	02	01	H2663_002_0	10	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													1092.93	33							1092.93	33																										33				33			33			
H2663	005	0	1	01	01	H2663_005_0	8	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													3.00		9.00						8.00		24.00						3.00		9.00																		8.00					8.00							
H2663	005	0	1	01	01	H2663_005_0	8	2	Preferred Brand	1	4	000001	1	2	100010110110101000000001				30		90	30		90	2	30		90							30				31	14										30.00		90.00						45.00		135.00						30.00		90.00																		45.00								45.00				
H2663	005	0	1	01	01	H2663_005_0	8	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													769.45	33							769.45	33																										33				33			33			
H2663	005	0	1	01	01	H2663_005_0	8	3	Non-Preferred Brand	1	4	100100	1	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										65.00		195.00						95.00		285.00						65.00		195.00																		95.00					95.00			95.00				
H2663	006	0	1	01	01	H2663_006_0	9	2	Preferred Brand	1	4	000001	1	2	100010110110101000000001				30		90	30		90	2	30		90							30				31	14										40.00		120.00						45.00		135.00						40.00		120.00																		45.00								45.00				
H2663	006	0	1	01	01	H2663_006_0	9	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													723.66	33							723.66	33																										33				33			33			
H2663	006	0	1	01	01	H2663_006_0	9	3	Non-Preferred Brand	1	4	100100	1	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										80.00		240.00						95.00		285.00						80.00		240.00																		95.00					95.00			95.00				
H2663	006	0	1	01	01	H2663_006_0	9	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													7.00		21.00						10.00		30.00						7.00		21.00																		10.00					10.00							
H2663	015	0	1	02	01	H2663_015_0	8	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		45.00		135.00																						45.00		135.00																		45.00								45.00				
H2663	015	0	1	02	01	H2663_015_0	8	3	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		80.00		240.00																						80.00		240.00																		80.00					80.00			80.00				
H2663	015	0	1	02	01	H2663_015_0	8	4	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					594.24	33																																										33				33			33			
H2663	015	0	1	02	01	H2663_015_0	8	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					3.00		9.00																						3.00		9.00																		3.00					3.00					1		
H2663	015	0	1	02	01	H2663_015_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					3.00		9.00																						3.00		9.00																		3.00					3.00							
H2667	001	0	1	01	01	H2667_001_0	8	3	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		80.00		240.00																						80.00		240.00																		80.00					80.00			80.00				
H2667	001	0	1	01	01	H2667_001_0	8	4	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					489.22	33																																										33				33			33			
H2667	001	0	1	01	01	H2667_001_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					5.00		15.00																						5.00		15.00																		5.00					5.00							
H2667	001	0	1	01	01	H2667_001_0	8	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		45.00		135.00																						45.00		135.00																		45.00								45.00				
H2667	017	0	1	02	01	H2667_017_0	10	3	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		85.00		255.00																						85.00		255.00																		85.00					85.00			85.00				
H2667	017	0	1	02	01	H2667_017_0	10	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		40.00		120.00																						40.00		120.00																		40.00								40.00				
H2667	017	0	1	02	01	H2667_017_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					5.00		15.00																						5.00		15.00																		5.00					5.00							
H2667	017	0	1	02	01	H2667_017_0	10	4	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					503.23	33																																										33				33			33			
H2672	001	0	1	01	01	H2672_001_0	9	4	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					753.58	33																																										33				33			33			
H2672	001	0	1	01	01	H2672_001_0	9	3	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		80.00		240.00																						80.00		240.00																		80.00					80.00			80.00				
H2672	001	0	1	01	01	H2672_001_0	9	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		45.00		135.00																						45.00		135.00																		45.00								45.00				
H2672	001	0	1	01	01	H2672_001_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					6.00		18.00																						6.00		18.00																		6.00					6.00							
H2672	008	0	1	01	01	H2672_008_0	11	3	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		80.00		240.00																						80.00		240.00																		80.00					80.00			80.00				
H2672	008	0	1	01	01	H2672_008_0	11	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		45.00		135.00																						45.00		135.00																		45.00								45.00				
H2672	008	0	1	01	01	H2672_008_0	11	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					6.00		18.00																						6.00		18.00																		6.00					6.00							
H2672	008	0	1	01	01	H2672_008_0	11	4	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					607.97	33																																										33				33			33			
H2672	009	0	1	02	01	H2672_009_0	12	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					6.00		18.00																						6.00		18.00																		6.00					6.00							
H2672	009	0	1	02	01	H2672_009_0	12	4	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					873.59	33																																										33				33			33			
H2672	009	0	1	02	01	H2672_009_0	12	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		45.00		135.00																						45.00		135.00																		45.00								45.00				
H2672	009	0	1	02	01	H2672_009_0	12	3	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		80.00		240.00																						80.00		240.00																		80.00					80.00			80.00				
H2672	010	0	1	01	01	H2672_010_0	9	4	Specialty Tier	1	4	001001	1	1	110000000010000000000101	30																			30		31		31	14					708.72	33																																										33				33			33			
H2672	010	0	1	01	01	H2672_010_0	9	3	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		80.00		240.00																						80.00		240.00																		80.00					80.00			80.00				
H2672	010	0	1	01	01	H2672_010_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					6.00		18.00																						0.00		0.00																		6.00					6.00							
H2672	010	0	1	01	01	H2672_010_0	9	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		40.00		120.00																						40.00		120.00																		40.00								40.00				
H2672	012	0	1	01	01	H2672_012_0	9	3	Non-Preferred Brand	1	4	100100	1	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										80.00		240.00						85.00		255.00						80.00		240.00																		85.00					85.00			85.00				
H2672	012	0	1	01	01	H2672_012_0	9	2	Preferred Brand	1	4	000001	1	2	100010110110101000000001				30		90	30		90	2	30		90							30				31	14										40.00		120.00						45.00		135.00						40.00		120.00																		45.00								45.00				
H2672	012	0	1	01	01	H2672_012_0	9	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													6.00		18.00						7.00		21.00						6.00		18.00																		7.00					7.00							
H2672	012	0	1	01	01	H2672_012_0	9	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													781.55	33							781.55	33																										33				33			33			
H2676	001	0	1	04	01	H2676_001_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00		2	3	1
H2676	001	0	1	04	01	H2676_001_0	6	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H2676	001	0	1	04	01	H2676_001_0	6	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1052.00	33																														33							33					33				33			33	2	3	
H2676	001	0	1	04	01	H2676_001_0	6	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					944.00	33																														33							33					33				33			33			
H2676	001	0	1	04	01	H2676_001_0	6	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H2676	001	0	1	04	01	H2676_001_0	6	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H2676	001	0	1	04	01	H2676_001_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H2676	001	0	1	04	01	H2676_001_0	6	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H2701	001	0	1	04	01	H2701_001_0	11	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	34	60	90							1	34	60	90							34		34	14				0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00							
H2701	001	0	1	04	01	H2701_001_0	11	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	34	60	90							1	34	60	90							34		34	14				5.00	10.00	15.00																						5.00	10.00	15.00																		5.00					5.00							
H2701	001	0	1	04	01	H2701_001_0	11	3	Preferred Brand	1	4	000001	1	2	111100000010111000000001	34	60	90							1	34	60	90							34				34	14		35.00	70.00	105.00																						35.00	70.00	105.00																		35.00								35.00				
H2701	001	0	1	04	01	H2701_001_0	11	4	Non-Preferred Brand	1	4	100000	1	1	111100000010111000000001	34	60	90							1	34	60	90							34				34	14					18.36	15	15	15																					15	15	15																	15							15			
H2701	001	0	1	04	01	H2701_001_0	11	5	Specialty Tier	1	4	101101	1	1	110000000010100000000111	34										34									34		34	14	34	14					528.17	33																							33																			33				33			33			
H2701	001	0	1	04	01	H2701_001_0	11	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	34	60	90							1	34	60	90							34		34	14				0.00	0.00	0.00																						0.00	0.00	0.00																		0.00				0.00	0.00					1		
H2701	001	0	1	04	01	H2701_001_0	11	2	Non-Preferred Generic	3	4	000100	1	2	011100000010111000000110	34	60	90							1	34	60	90							34		34	14				5.00	10.00	15.00																						5.00	10.00	15.00																		5.00					5.00					1		
H2701	003	0	1	04	01	H2701_003_0	11	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	34	60	90							1	34	60	90							34		34	14				0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00							
H2701	003	0	1	04	01	H2701_003_0	11	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	34	60	90							1	34	60	90							34		34	14				20.00	40.00	60.00																						20.00	40.00	60.00																		20.00					20.00							
H2701	003	0	1	04	01	H2701_003_0	11	3	Preferred Brand	1	4	000001	1	2	111100000010111000000001	34	60	90							1	34	60	90							34				34	14		45.00	90.00	135.00																						45.00	90.00	135.00																		45.00								45.00				
H2701	003	0	1	04	01	H2701_003_0	11	4	Non-Preferred Brand	1	4	100000	1	1	111100000010111000000001	34	60	90							1	34	60	90							34				34	14					29.54	25	25	25																					25	25	25																	25							25			
H2701	003	0	1	04	01	H2701_003_0	11	5	Specialty Tier	1	4	101101	1	1	110000000010100000000111	34										34									34		34	14	34	14					452.73	33																							33																			33				33			33			
H2701	004	0	1	04	01	H2701_004_0	13	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	34	60	90							1	34	60	90							34		34	14				15.00	30.00	45.00																						15.00	30.00	45.00																		15.00					15.00							
H2701	004	0	1	04	01	H2701_004_0	13	3	Preferred Brand	1	4	000001	1	2	111100000010111000000001	34	60	90							1	34	60	90							34				34	14		40.00	80.00	120.00																						40.00	80.00	120.00																		40.00								40.00				
H2701	004	0	1	04	01	H2701_004_0	13	4	Non-Preferred Brand	1	4	100000	1	1	111100000010111000000001	34	60	90							1	34	60	90							34				34	14					24.19	20	20	20																					20	20	20																	20							20			
H2701	004	0	1	04	01	H2701_004_0	13	5	Specialty Tier	1	4	101101	1	1	110000000010100000000111	34										34									34		34	14	34	14					497.10	33																							33																			33				33			33			
H2701	004	0	1	04	01	H2701_004_0	13	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	34	60	90							1	34	60	90							34		34	14				0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00							
H2701	005	0	1	04	01	H2701_005_0	11	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	34	60	90							1	34	60	90							34		34	14				0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00							
H2701	005	0	1	04	01	H2701_005_0	11	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	34	60	90							1	34	60	90							34		34	14				15.00	30.00	45.00																						15.00	30.00	45.00																		15.00					15.00							
H2701	005	0	1	04	01	H2701_005_0	11	3	Preferred Brand	1	4	000001	1	2	111100000010111000000001	34	60	90							1	34	60	90							34				34	14		40.00	80.00	120.00																						40.00	80.00	120.00																		40.00								40.00				
H2701	005	0	1	04	01	H2701_005_0	11	4	Non-Preferred Brand	1	4	100000	1	1	111100000010111000000001	34	60	90							1	34	60	90							34				34	14					24.19	20	20	20																					20	20	20																	20							20			
H2701	005	0	1	04	01	H2701_005_0	11	5	Specialty Tier	1	4	101101	1	1	110000000010100000000111	34										34									34		34	14	34	14					497.10	33																							33																			33				33			33			
H2773	001	0	1	01	01	H2773_001_0	9	2	Preferred Brand	1	4	000101	3	2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14		30.00		90.00																						30.00		60.00																		30.00					30.00			30.00				
H2773	001	0	1	01	01	H2773_001_0	9	1	Preferred Generic	3	4	001000	1	2	010100000010101000000110	30		90							2	30		90							30		31	14				5.00		15.00																						5.00		10.00																		5.00					5.00					1		
H2773	001	0	1	01	01	H2773_001_0	9	4	Specialty Tier	1	4	110000	1	1	110000000010000000000111	30																			30		31	14	31	14					33.00	33																																										33				33			33			
H2773	001	0	1	01	01	H2773_001_0	9	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000000000111	30		90							2										30		31	14	31	14		55.00		165.00																																										55.00					55.00			55.00				
H2773	001	0	1	01	01	H2773_001_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010101000000110	30		90							2	30		90							30		31	14				4.00		12.00																						4.00		8.00																		4.00					4.00							
H2773	002	0	1	01	01	H2773_002_0	9	4	Specialty Tier	1	4	110000	1	1	110000000010000000000111	30																			30		31	14	31	14					33.00	33																																										33				33			33			
H2773	002	0	1	01	01	H2773_002_0	9	2	Preferred Brand	1	4	000101	3	2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14		30.00		90.00																						30.00		60.00																		30.00					30.00			30.00				
H2773	002	0	1	01	01	H2773_002_0	9	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000000000111	30		90							2										30		31	14	31	14		55.00		165.00																																										55.00					55.00			55.00				
H2773	002	0	1	01	01	H2773_002_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010101000000110	30		90							2	30		90							30		31	14				4.00		12.00																						4.00		8.00																		4.00					4.00							
H2773	003	0	1	01	01	H2773_003_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010101000000110	30		90							2	30		90							30		31	14				2.00		6.00																						2.00		4.00																		2.00					2.00							
H2773	003	0	1	01	01	H2773_003_0	7	2	Preferred Brand	1	4	000101	3	2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14		25.00		75.00																						25.00		50.00																		25.00					25.00			25.00				
H2773	003	0	1	01	01	H2773_003_0	7	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000000000111	30		90							2										30		31	14	31	14		55.00		165.00																																										55.00					55.00			55.00				
H2773	003	0	1	01	01	H2773_003_0	7	4	Specialty Tier	1	4	110000	1	1	110000000010000000000111	30																			30		31	14	31	14					33.00	33																																										33				33			33			
H2773	013	0	1	01	01	H2773_013_0	12	4	Specialty Tier	1	4	110000	1	1	110000000010000000000111	30																			30		31	14	31	14					33.00	33																																										33				33			33			
H2773	013	0	1	01	01	H2773_013_0	12	2	Preferred Brand	1	4	000101	3	2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14		30.00		90.00																						30.00		60.00																		30.00					30.00			30.00				
H2773	013	0	1	01	01	H2773_013_0	12	1	Preferred Generic	1	4	001000	1	2	010100000010101000000110	30		90							2	30		90							30		31	14				4.00		12.00																						4.00		8.00																		4.00					4.00							
H2773	013	0	1	01	01	H2773_013_0	12	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000000000111	30		90							2										30		31	14	31	14		55.00		165.00																																										55.00					55.00			55.00				
H2773	013	0	1	01	01	H2773_013_0	12	1	Preferred Generic	3	4	001000	1	2	010100000010101000000110	30		90							2	30		90							30		31	14				10.00		30.00																						10.00		20.00																		10.00					10.00					1		
H2775	082	0	1	04	01	H2775_082_0	8	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		80.00		200.00																													80.00		160.00					80.00		200.00				80.00								80.00				
H2775	082	0	1	04	01	H2775_082_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					500.00	33																														33							33					33				33			33			
H2775	082	0	1	04	01	H2775_082_0	8	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		40.00		100.00																													40.00		80.00					40.00		100.00				40.00								40.00				
H2775	082	0	1	04	01	H2775_082_0	8	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		7.00		17.50																													7.00		14.00					7.00		17.50				7.00					7.00			7.00				
H2775	082	0	1	04	01	H2775_082_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					2.00		5.00																													2.00		4.00					2.00		5.00				2.00					2.00							
H2775	083	0	1	04	01	H2775_083_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		40.00		100.00																													40.00		80.00					40.00		100.00				40.00								40.00				
H2775	083	0	1	04	01	H2775_083_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		80.00		200.00																													80.00		160.00					80.00		200.00				80.00								80.00				
H2775	083	0	1	04	01	H2775_083_0	7	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		7.00		17.50																													7.00		14.00					7.00		17.50				7.00					7.00			7.00				
H2775	083	0	1	04	01	H2775_083_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					2.00		5.00																													2.00		4.00					2.00		5.00				2.00					2.00							
H2775	083	0	1	04	01	H2775_083_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					500.00	33																														33							33					33				33			33			
H2775	084	0	1	04	01	H2775_084_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					5.00		12.50																													5.00		10.00					5.00		12.50				5.00					5.00							
H2775	084	0	1	04	01	H2775_084_0	6	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		12.00		30.00																													12.00		24.00					12.00		30.00				12.00					12.00			12.00				
H2775	084	0	1	04	01	H2775_084_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		45.00		112.50																													45.00		90.00					45.00		112.50				45.00								45.00				
H2775	084	0	1	04	01	H2775_084_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		95.00		237.50																													95.00		190.00					95.00		237.50				95.00								95.00				
H2775	084	0	1	04	01	H2775_084_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					435.00	29																														29							29					29				29			29			
H2775	085	0	1	04	01	H2775_085_0	7	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		7.00		17.50																													7.00		14.00					7.00		17.50				7.00					7.00			7.00				
H2775	085	0	1	04	01	H2775_085_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					2.00		5.00																													2.00		4.00					2.00		5.00				2.00					2.00							
H2775	085	0	1	04	01	H2775_085_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		40.00		100.00																													40.00		80.00					40.00		100.00				40.00								40.00				
H2775	085	0	1	04	01	H2775_085_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					500.00	33																														33							33					33				33			33			
H2775	085	0	1	04	01	H2775_085_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		80.00		200.00																													80.00		160.00					80.00		200.00				80.00								80.00				
H2775	088	0	1	04	01	H2775_088_0	11	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		45.00		112.50																													45.00		90.00					45.00		112.50				45.00								45.00				
H2775	088	0	1	04	01	H2775_088_0	11	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		95.00		237.50																													95.00		190.00					95.00		237.50				95.00								95.00				
H2775	088	0	1	04	01	H2775_088_0	11	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		12.00		30.00																													12.00		24.00					12.00		30.00				12.00					12.00			12.00				
H2775	088	0	1	04	01	H2775_088_0	11	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					5.00		12.50																													5.00		10.00					5.00		12.50				5.00					5.00							
H2775	088	0	1	04	01	H2775_088_0	11	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					435.00	29																														29							29					29				29			29			
H2775	089	0	1	04	01	H2775_089_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					435.00	29																														29							29					29				29			29			
H2775	089	0	1	04	01	H2775_089_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		95.00		237.50																													95.00		190.00					95.00		237.50				95.00								95.00				
H2775	089	0	1	04	01	H2775_089_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		45.00		112.50																													45.00		90.00					45.00		112.50				45.00								45.00				
H2775	089	0	1	04	01	H2775_089_0	6	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		12.00		30.00																													12.00		24.00					12.00		30.00				12.00					12.00			12.00				
H2775	089	0	1	04	01	H2775_089_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					5.00		12.50																													5.00		10.00					5.00		12.50				5.00					5.00							
H2775	091	0	1	04	01	H2775_091_0	6	4	Non-Preferred Brand	1	3	100000		2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		95.00		237.50																													95.00		190.00					95.00		237.50				95.00								95.00				
H2775	091	0	1	04	01	H2775_091_0	6	5	Specialty Tier	1	3	010010		1	110000000010000100100101	30													30			30			30		34		34	14					435.00	29																														29							29					29				29			29			
H2775	091	0	1	04	01	H2775_091_0	6	3	Preferred Brand	1	3	000001		2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		45.00		112.50																													45.00		90.00					45.00		112.50				45.00								45.00				
H2775	091	0	1	04	01	H2775_091_0	6	1	Preferred Generic	1	3	001000		2	010100000010000101101100	30		90							2				30		90	30		90	30		34					5.00		12.50																													5.00		10.00					5.00		12.50				5.00					5.00							
H2775	091	0	1	04	01	H2775_091_0	6	2	Non-Preferred Generic	1	3	000110		2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		12.00		30.00																													12.00		24.00					12.00		30.00				12.00					12.00			12.00				
H2775	098	0	1	04	01	H2775_098_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		80.00		200.00																													80.00		160.00					80.00		200.00				80.00								80.00				
H2775	098	0	1	04	01	H2775_098_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		40.00		100.00																													40.00		80.00					40.00		100.00				40.00								40.00				
H2775	098	0	1	04	01	H2775_098_0	7	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		7.00		17.50																													7.00		14.00					7.00		17.50				7.00					7.00			7.00				
H2775	098	0	1	04	01	H2775_098_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					2.00		5.00																													2.00		4.00					2.00		5.00				2.00					2.00							
H2775	098	0	1	04	01	H2775_098_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					500.00	33																														33							33					33				33			33			
H2802	001	0	1	01	01	H2802_001_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H2802	001	0	1	01	01	H2802_001_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H2802	001	0	1	01	01	H2802_001_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		44.00		132.00																															122.00							132.00				44.00					44.00			44.00				
H2802	001	0	1	01	01	H2802_001_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		92.00		276.00																															266.00							276.00				92.00					92.00			92.00				
H2802	001	0	1	01	01	H2802_001_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					690.00	33		33																														33							33			33				33			33			
H2803	001	0	1	02	01	H2803_001_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H2803	001	0	1	02	01	H2803_001_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H2803	001	0	1	02	01	H2803_001_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H2803	001	0	1	02	01	H2803_001_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					388.00	33		33																														33							33			33				33			33			
H2803	001	0	1	02	01	H2803_001_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H2803	002	0	1	02	01	H2803_002_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H2803	002	0	1	02	01	H2803_002_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H2803	002	0	1	02	01	H2803_002_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H2803	002	0	1	02	01	H2803_002_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H2803	002	0	1	02	01	H2803_002_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					656.00	33		33																														33							33			33				33			33			
H2810	001	0	1	04	01	H2810_001_0	7	1	Preferred Generic	1	3	001000		2	010100000010101000000100	30		90							1	30		90							30		31					3.00		9.00																						3.00		9.00																		3.00					3.00							
H2810	001	0	1	04	01	H2810_001_0	7	2	Non-Preferred Generic	1	3	000100		2	010100000010101000000100	30		90							1	30		90							30		31					10.00		30.00																						10.00		30.00																		10.00					10.00							
H2810	001	0	1	04	01	H2810_001_0	7	4	Non-Preferred Brand	1	3	100000		1	110100000010101000000001	30		90							1	30		90							30				31	14					77.72	50		50																					50		50																	50							50			
H2810	001	0	1	04	01	H2810_001_0	7	3	Preferred Brand	1	3	000001		2	110100000010101000000001	30		90							1	30		90							30				31	14		14.00		42.00																						14.00		42.00																		14.00								14.00				
H2816	013	0	1	09	04	H2816_013_0	7	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		7.00		17.50																													7.00		14.00					7.00		17.50				7.00					7.00			7.00				
H2816	013	0	1	09	04	H2816_013_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					2.00		5.00																													2.00		4.00					2.00		5.00				2.00					2.00							
H2816	013	0	1	09	04	H2816_013_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		40.00		100.00																													40.00		80.00					40.00		100.00				40.00								40.00				
H2816	013	0	1	09	04	H2816_013_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		80.00		200.00																													80.00		160.00					80.00		200.00				80.00								80.00				
H2816	013	0	1	09	04	H2816_013_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					500.00	33																														33							33					33				33			33			
H2816	014	0	1	09	04	H2816_014_0	7	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		7.00		17.50																													7.00		14.00					7.00		17.50				7.00					7.00			7.00				
H2816	014	0	1	09	04	H2816_014_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					2.00		5.00																													2.00		4.00					2.00		5.00				2.00					2.00							
H2816	014	0	1	09	04	H2816_014_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		40.00		100.00																													40.00		80.00					40.00		100.00				40.00								40.00				
H2816	014	0	1	09	04	H2816_014_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					500.00	33																														33							33					33				33			33			
H2816	014	0	1	09	04	H2816_014_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		80.00		200.00																													80.00		160.00					80.00		200.00				80.00								80.00				
H2816	019	0	1	09	04	H2816_019_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					5.00		12.50																													5.00		10.00					5.00		12.50				5.00					5.00							
H2816	019	0	1	09	04	H2816_019_0	7	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		12.00		30.00																													12.00		24.00					12.00		30.00				12.00					12.00			12.00				
H2816	019	0	1	09	04	H2816_019_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		45.00		112.50																													45.00		90.00					45.00		112.50				45.00								45.00				
H2816	019	0	1	09	04	H2816_019_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		95.00		237.50																													95.00		190.00					95.00		237.50				95.00								95.00				
H2816	019	0	1	09	04	H2816_019_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					435.00	29																														29							29					29				29			29			
H2816	020	0	1	09	04	H2816_020_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					435.00	29																														29							29					29				29			29			
H2816	020	0	1	09	04	H2816_020_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					5.00		12.50																													5.00		10.00					5.00		12.50				5.00					5.00							
H2816	020	0	1	09	04	H2816_020_0	6	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		12.00		30.00																													12.00		24.00					12.00		30.00				12.00					12.00			12.00				
H2816	020	0	1	09	04	H2816_020_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		45.00		112.50																													45.00		90.00					45.00		112.50				45.00								45.00				
H2816	020	0	1	09	04	H2816_020_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		95.00		237.50																													95.00		190.00					95.00		237.50				95.00								95.00				
H2816	021	0	1	09	04	H2816_021_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		95.00		237.50																													95.00		190.00					95.00		237.50				95.00								95.00				
H2816	021	0	1	09	04	H2816_021_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					435.00	29																														29							29					29				29			29			
H2816	021	0	1	09	04	H2816_021_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		45.00		112.50																													45.00		90.00					45.00		112.50				45.00								45.00				
H2816	021	0	1	09	04	H2816_021_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					5.00		12.50																													5.00		10.00					5.00		12.50				5.00					5.00							
H2816	021	0	1	09	04	H2816_021_0	6	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		12.00		30.00																													12.00		24.00					12.00		30.00				12.00					12.00			12.00				
H2816	022	0	1	09	04	H2816_022_0	6	4	Non-Preferred Brand	1	3	100000		2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		95.00		237.50																													95.00		190.00					95.00		237.50				95.00								95.00				
H2816	022	0	1	09	04	H2816_022_0	6	5	Specialty Tier	1	3	010010		1	110000000010000100100101	30													30			30			30		34		34	14					435.00	29																														29							29					29				29			29			
H2816	022	0	1	09	04	H2816_022_0	6	1	Preferred Generic	1	3	001000		2	010100000010000101101100	30		90							2				30		90	30		90	30		34					5.00		12.50																													5.00		10.00					5.00		12.50				5.00					5.00							
H2816	022	0	1	09	04	H2816_022_0	6	3	Preferred Brand	1	3	000001		2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		45.00		112.50																													45.00		90.00					45.00		112.50				45.00								45.00				
H2816	022	0	1	09	04	H2816_022_0	6	2	Non-Preferred Generic	1	3	000110		2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		12.00		30.00																													12.00		24.00					12.00		30.00				12.00					12.00			12.00				
H2816	027	0	1	09	04	H2816_027_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					500.00	33																														33							33					33				33			33			
H2816	027	0	1	09	04	H2816_027_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		40.00		100.00																													40.00		80.00					40.00		100.00				40.00								40.00				
H2816	027	0	1	09	04	H2816_027_0	7	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		7.00		17.50																													7.00		14.00					7.00		17.50				7.00					7.00			7.00				
H2816	027	0	1	09	04	H2816_027_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					2.00		5.00																													2.00		4.00					2.00		5.00				2.00					2.00							
H2816	027	0	1	09	04	H2816_027_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		80.00		200.00																													80.00		160.00					80.00		200.00				80.00								80.00				
H2816	028	0	1	09	04	H2816_028_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					500.00	33																														33							33					33				33			33			
H2816	028	0	1	09	04	H2816_028_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		80.00		200.00																													80.00		160.00					80.00		200.00				80.00								80.00				
H2816	028	0	1	09	04	H2816_028_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		40.00		100.00																													40.00		80.00					40.00		100.00				40.00								40.00				
H2816	028	0	1	09	04	H2816_028_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					2.00		5.00																													2.00		4.00					2.00		5.00				2.00					2.00							
H2816	028	0	1	09	04	H2816_028_0	7	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		7.00		17.50																													7.00		14.00					7.00		17.50				7.00					7.00			7.00				
H2836	001	0	1	04	01	H2836_001_0	15	5	Injectable Drugs	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					91.00	33	33	33																					33	33	33																	33				33			33			
H2836	001	0	1	04	01	H2836_001_0	15	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		85.00	170.00	255.00																						85.00	170.00	212.50																		85.00					85.00			85.00				
H2836	001	0	1	04	01	H2836_001_0	15	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		40.00	80.00	120.00																						40.00	80.00	100.00																		40.00					40.00			40.00				
H2836	001	0	1	04	01	H2836_001_0	15	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				10.00	20.00	30.00																						10.00	20.00	15.00																		10.00					10.00							
H2836	001	0	1	04	01	H2836_001_0	15	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				6.00	12.00	18.00																						6.00	12.00	9.00																		6.00					6.00							
H2836	001	0	1	04	01	H2836_001_0	15	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					630.00	33																							33																			33				33			33			
H2905	001	0	1	04	01	H2905_001_0	8	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H2905	001	0	1	04	01	H2905_001_0	8	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					648.00	33		33																														33							33			33				33			33			
H2905	001	0	1	04	01	H2905_001_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H2905	001	0	1	04	01	H2905_001_0	8	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		6.00		18.00																															12.00							18.00				6.00					6.00			6.00				
H2905	001	0	1	04	01	H2905_001_0	8	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		44.00		132.00																															122.00							132.00				44.00					44.00			44.00				
H2906	003	0	1	04	01	H2906_003_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				2.00		5.00																								4.00																		2.00					2.00							
H2906	003	0	1	04	01	H2906_003_0	7	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				2.00		5.00																								4.00																		2.00					2.00					1		
H2906	003	0	1	04	01	H2906_003_0	7	6	Select Diabetic Drugs	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		20.00		50.00																								40.00																		20.00								20.00		1		
H2906	003	0	1	04	01	H2906_003_0	7	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		80.00		200.00																								160.00																		80.00								80.00		1		
H2906	003	0	1	04	01	H2906_003_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				4.00		10.00																								8.00																		4.00					4.00							
H2906	003	0	1	04	01	H2906_003_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		40.00		100.00																								80.00																		40.00								40.00				
H2906	003	0	1	04	01	H2906_003_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		70.00		175.00																								140.00																		70.00								70.00				
H2906	003	0	1	04	01	H2906_003_0	7	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				4.00		10.00																								8.00																		4.00					4.00					1		
H2906	003	0	1	04	01	H2906_003_0	7	6	Select Diabetic Drugs	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		10.00		25.00																								20.00																		10.00								10.00				
H2906	003	0	1	04	01	H2906_003_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							1			90							30		31	14	31	14					264.00	33		33																							33																	33				33			33			
H2906	005	0	1	04	01	H2906_005_0	7	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				6.00		15.00																								12.00																		6.00					6.00					1		
H2906	005	0	1	04	01	H2906_005_0	7	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				2.00		5.00																								4.00																		2.00					2.00					1		
H2906	005	0	1	04	01	H2906_005_0	7	6	Select Diabetic Drugs	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		10.00		25.00																								20.00																		10.00								10.00				
H2906	005	0	1	04	01	H2906_005_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							1			90							30		31	14	31	14					264.00	33		33																							33																	33				33			33			
H2906	005	0	1	04	01	H2906_005_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		80.00		200.00																								160.00																		80.00								80.00				
H2906	005	0	1	04	01	H2906_005_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		45.00		112.50																								90.00																		45.00								45.00				
H2906	005	0	1	04	01	H2906_005_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				2.00		5.00																								4.00																		2.00					2.00							
H2906	005	0	1	04	01	H2906_005_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				6.00		15.00																								12.00																		6.00					6.00							
H2906	006	0	1	04	01	H2906_006_0	7	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				4.00		10.00																								8.00																		4.00					4.00					1		
H2906	006	0	1	04	01	H2906_006_0	7	6	Select Diabetic Drugs	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		10.00		25.00																								20.00																		10.00								10.00				
H2906	006	0	1	04	01	H2906_006_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							1			90							30		31	14	31	14					264.00	33		33																							33																	33				33			33			
H2906	006	0	1	04	01	H2906_006_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		80.00		200.00																								160.00																		80.00								80.00				
H2906	006	0	1	04	01	H2906_006_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		45.00		112.50																								90.00																		45.00								45.00				
H2906	006	0	1	04	01	H2906_006_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				10.00		25.00																								20.00																		10.00					10.00							
H2906	006	0	1	04	01	H2906_006_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				4.00		10.00																								8.00																		4.00					4.00							
H2906	006	0	1	04	01	H2906_006_0	7	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				10.00		25.00																								20.00																		10.00					10.00					1		
H2911	001	0	1	01	01	H2911_001_0	12	1	Preferred Generic	1	4	001010	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		2.00		6.00																						2.00		4.00																		2.00					2.00			2.00				
H2911	001	0	1	01	01	H2911_001_0	12	2	Non-Preferred Generic	1	4	000101	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		11.00		33.00																						11.00		22.00																		11.00					11.00			11.00				
H2911	001	0	1	01	01	H2911_001_0	12	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					592.00	33																							33																			33				33			33			
H2911	001	0	1	01	01	H2911_001_0	12	4	Non-Preferred Brand	1	4	110000	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		95.00		285.00																						95.00		237.50																		95.00					95.00			95.00				
H2911	001	0	1	01	01	H2911_001_0	12	3	Preferred Brand	1	4	000101	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		45.00		135.00																						45.00		112.50																		45.00					45.00			45.00				
H2931	002	0	1	02	01	H2931_002_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00							
H2931	002	0	1	02	01	H2931_002_0	10	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		5.00		15.00																															5.00							15.00				5.00					5.00			5.00				
H2931	002	0	1	02	01	H2931_002_0	10	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		38.00		114.00																															104.00							114.00				38.00					38.00			38.00				
H2931	002	0	1	02	01	H2931_002_0	10	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		92.00		276.00																															266.00							276.00				92.00					92.00			92.00				
H2931	002	0	1	02	01	H2931_002_0	10	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					740.00	33		33																														33							33			33				33			33			
H2931	002	0	1	02	01	H2931_002_0	10	1	Preferred Generic	3	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00					1		
H2931	002	0	1	02	01	H2931_002_0	10	2	Non-Preferred Generic	3	4	000110	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		5.00		15.00																															5.00							15.00				5.00					5.00			5.00		1		
H2931	004	0	1	01	01	H2931_004_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00							
H2931	004	0	1	01	01	H2931_004_0	9	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		8.00		24.00																															16.00							24.00				8.00					8.00			8.00				
H2931	004	0	1	01	01	H2931_004_0	9	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H2931	004	0	1	01	01	H2931_004_0	9	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H2931	004	0	1	01	01	H2931_004_0	9	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					425.00	33		33																														33							33			33				33			33			
H2931	004	0	1	01	01	H2931_004_0	9	1	Preferred Generic	3	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					10.00		30.00																															20.00							30.00				10.00					10.00					1		
H2931	004	0	1	01	01	H2931_004_0	9	2	Non-Preferred Generic	3	4	000110	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		12.00		36.00																															24.00							36.00				12.00					12.00			12.00		1		
H2944	004	0	1	09	04	H2944_004_0	6	2	Non-Preferred Generic	1	3	000101		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H2944	004	0	1	09	04	H2944_004_0	6	3	Preferred Brand	1	3	000101		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		37.00		111.00																													37.00		101.00					37.00		111.00				37.00					37.00			37.00				
H2944	004	0	1	09	04	H2944_004_0	6	4	Non-Preferred Brand	1	3	110000		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		75.00		225.00																													75.00		215.00					75.00		225.00				75.00					75.00			75.00				
H2944	004	0	1	09	04	H2944_004_0	6	5	Specialty Tier	1	3	010010		1	110000000010000100100101	30													30			30			30		31		31	14					663.00	26																														26							26					26				26			26			
H2944	004	0	1	09	04	H2944_004_0	6	1	Preferred Generic	1	3	001010		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H2944	013	0	1	09	04	H2944_013_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1052.00	33																														33							33					33				33			33	2	3	
H2944	013	0	1	09	04	H2944_013_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00		2	3	
H2944	013	0	1	09	04	H2944_013_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		42.00		126.00																													42.00		116.00					42.00		126.00				42.00					42.00			42.00		2	2	
H2944	013	0	1	09	04	H2944_013_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		14.00		42.00																													0.00		0.00					14.00		42.00				14.00					14.00			14.00		2	2	
H2944	013	0	1	09	04	H2944_013_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H2944	013	0	1	09	04	H2944_013_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		14.00		42.00																													0.00		0.00					14.00		42.00				14.00					14.00			14.00				
H2944	013	0	1	09	04	H2944_013_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		42.00		126.00																													42.00		116.00					42.00		126.00				42.00					42.00			42.00				
H2944	013	0	1	09	04	H2944_013_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00		2	3	
H2944	013	0	1	09	04	H2944_013_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					893.00	33																														33							33					33				33			33			
H2944	013	0	1	09	04	H2944_013_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00				
H2944	019	0	1	09	04	H2944_019_0	5	4	Non-Preferred Brand	1	3	110000		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H2944	019	0	1	09	04	H2944_019_0	5	5	Specialty Tier	1	3	010010		1	110000000010000100100101	30													30			30			30		31		31	14					726.00	29																														29							29					29				29			29			
H2944	019	0	1	09	04	H2944_019_0	5	3	Preferred Brand	1	3	000101		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H2944	019	0	1	09	04	H2944_019_0	5	2	Non-Preferred Generic	1	3	000101		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H2944	019	0	1	09	04	H2944_019_0	5	1	Preferred Generic	1	3	001010		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H2944	024	0	1	09	04	H2944_024_0	8	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					745.00	33																														33							33					33				33			33	2	3	
H2944	024	0	1	09	04	H2944_024_0	8	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H2944	024	0	1	09	04	H2944_024_0	8	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H2944	024	0	1	09	04	H2944_024_0	8	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		39.00		117.00																													39.00		107.00					39.00		117.00				39.00					39.00			39.00				
H2944	024	0	1	09	04	H2944_024_0	8	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H2944	024	0	1	09	04	H2944_024_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					609.00	33																														33							33					33				33			33			
H2944	024	0	1	09	04	H2944_024_0	8	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H2944	024	0	1	09	04	H2944_024_0	8	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H2944	024	0	1	09	04	H2944_024_0	8	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H2944	024	0	1	09	04	H2944_024_0	8	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		39.00		117.00																													39.00		107.00					39.00		117.00				39.00					39.00			39.00		2	2	
H2944	041	0	1	09	04	H2944_041_0	6	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					806.00	33																														33							33					33				33			33			
H2944	041	0	1	09	04	H2944_041_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H2944	041	0	1	09	04	H2944_041_0	6	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H2944	041	0	1	09	04	H2944_041_0	6	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H2944	041	0	1	09	04	H2944_041_0	6	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					907.00	33																														33							33					33				33			33	2	3	
H2944	041	0	1	09	04	H2944_041_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00		2	3	1
H2944	041	0	1	09	04	H2944_041_0	6	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H2944	041	0	1	09	04	H2944_041_0	6	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H2944	052	0	1	09	04	H2944_052_0	6	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H2944	052	0	1	09	04	H2944_052_0	6	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H2944	052	0	1	09	04	H2944_052_0	6	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1025.00	33																														33							33					33				33			33	2	3	
H2944	052	0	1	09	04	H2944_052_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H2944	052	0	1	09	04	H2944_052_0	6	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H2944	052	0	1	09	04	H2944_052_0	6	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H2944	052	0	1	09	04	H2944_052_0	6	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					843.00	33																														33							33					33				33			33			
H2944	052	0	1	09	04	H2944_052_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H2944	078	0	1	09	04	H2944_078_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H2944	078	0	1	09	04	H2944_078_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H2944	078	0	1	09	04	H2944_078_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					973.00	33																														33							33					33				33			33	2	3	
H2944	078	0	1	09	04	H2944_078_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H2944	078	0	1	09	04	H2944_078_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H2944	078	0	1	09	04	H2944_078_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H2944	078	0	1	09	04	H2944_078_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H2944	078	0	1	09	04	H2944_078_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					845.00	33																														33							33					33				33			33			
H2944	078	0	1	09	04	H2944_078_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H2944	078	0	1	09	04	H2944_078_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H2944	085	0	1	09	04	H2944_085_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00				
H2944	085	0	1	09	04	H2944_085_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H2944	085	0	1	09	04	H2944_085_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H2944	085	0	1	09	04	H2944_085_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H2944	085	0	1	09	04	H2944_085_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1152.00	33																														33							33					33				33			33	2	3	
H2944	085	0	1	09	04	H2944_085_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1030.00	33																														33							33					33				33			33			
H2944	085	0	1	09	04	H2944_085_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H2944	085	0	1	09	04	H2944_085_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H2944	085	0	1	09	04	H2944_085_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H2944	085	0	1	09	04	H2944_085_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00		2	3	1
H2944	106	0	1	09	04	H2944_106_0	6	4	Specialty Tier	1	3	010010		1	110000000010000100100101	30													30			30			30		31		31	14					987.00	28																														28							28					28				28			28			
H2944	106	0	1	09	04	H2944_106_0	6	3	Non-Preferred Brand	1	3	100100		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H2944	106	0	1	09	04	H2944_106_0	6	2	Preferred Brand	1	3	010001		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H2944	106	0	1	09	04	H2944_106_0	6	1	Preferred Generic	1	3	001010		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H2944	114	0	1	09	04	H2944_114_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H2944	114	0	1	09	04	H2944_114_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H2944	114	0	1	09	04	H2944_114_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1066.00	33																														33							33					33				33			33	2	3	
H2944	114	0	1	09	04	H2944_114_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H2944	114	0	1	09	04	H2944_114_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H2944	114	0	1	09	04	H2944_114_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H2944	114	0	1	09	04	H2944_114_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H2944	114	0	1	09	04	H2944_114_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					912.00	33																														33							33					33				33			33			
H2944	114	0	1	09	04	H2944_114_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H2944	114	0	1	09	04	H2944_114_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H2944	124	0	1	09	04	H2944_124_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H2944	124	0	1	09	04	H2944_124_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H2944	124	0	1	09	04	H2944_124_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H2944	124	0	1	09	04	H2944_124_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H2944	124	0	1	09	04	H2944_124_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					876.00	33																														33							33					33				33			33			
H2944	124	0	1	09	04	H2944_124_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H2944	124	0	1	09	04	H2944_124_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H2944	124	0	1	09	04	H2944_124_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H2944	124	0	1	09	04	H2944_124_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H2944	124	0	1	09	04	H2944_124_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1009.00	33																														33							33					33				33			33	2	3	
H2944	127	0	1	09	04	H2944_127_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					929.00	33																														33							33					33				33			33	2	3	
H2944	127	0	1	09	04	H2944_127_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H2944	127	0	1	09	04	H2944_127_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H2944	127	0	1	09	04	H2944_127_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H2944	127	0	1	09	04	H2944_127_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H2944	127	0	1	09	04	H2944_127_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					842.00	33																														33							33					33				33			33			
H2944	127	0	1	09	04	H2944_127_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H2944	127	0	1	09	04	H2944_127_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H2944	127	0	1	09	04	H2944_127_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H2944	127	0	1	09	04	H2944_127_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H2944	128	0	1	09	04	H2944_128_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H2944	128	0	1	09	04	H2944_128_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H2944	128	0	1	09	04	H2944_128_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		44.00		132.00																													44.00		122.00					44.00		132.00				44.00					44.00			44.00				
H2944	128	0	1	09	04	H2944_128_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H2944	128	0	1	09	04	H2944_128_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H2944	128	0	1	09	04	H2944_128_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H2944	128	0	1	09	04	H2944_128_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		44.00		132.00																													44.00		122.00					44.00		132.00				44.00					44.00			44.00		2	2	
H2944	128	0	1	09	04	H2944_128_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H2944	128	0	1	09	04	H2944_128_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					796.00	33																														33							33					33				33			33			
H2944	128	0	1	09	04	H2944_128_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					875.00	33																														33							33					33				33			33	2	3	
H2944	133	0	1	09	04	H2944_133_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					926.00	33																														33							33					33				33			33			
H2944	133	0	1	09	04	H2944_133_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00		2	3	
H2944	133	0	1	09	04	H2944_133_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00		2	2	
H2944	133	0	1	09	04	H2944_133_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H2944	133	0	1	09	04	H2944_133_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00				
H2944	133	0	1	09	04	H2944_133_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H2944	133	0	1	09	04	H2944_133_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1095.00	33																														33							33					33				33			33	2	3	
H2944	133	0	1	09	04	H2944_133_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H2944	133	0	1	09	04	H2944_133_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00				
H2944	133	0	1	09	04	H2944_133_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H2944	137	0	1	09	04	H2944_137_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H2944	137	0	1	09	04	H2944_137_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00		2	2	
H2944	137	0	1	09	04	H2944_137_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1169.00	33																														33							33					33				33			33	2	3	
H2944	137	0	1	09	04	H2944_137_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1040.00	33																														33							33					33				33			33			
H2944	137	0	1	09	04	H2944_137_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H2944	137	0	1	09	04	H2944_137_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H2944	137	0	1	09	04	H2944_137_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00				
H2944	137	0	1	09	04	H2944_137_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00				
H2944	137	0	1	09	04	H2944_137_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00		2	3	
H2944	137	0	1	09	04	H2944_137_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H2944	204	0	1	09	04	H2944_204_0	6	3	Preferred Brand	3	4	000101	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													20.00	17		17					31.00	25		25												17		17					25		25			25				25			25	2	2	
H2944	204	0	1	09	04	H2944_204_0	6	4	Non-Preferred Brand	3	4	110000	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													117.00	30		30					120.00	50		50												30		30					50		50			50				50			50	2	3	
H2944	204	0	1	09	04	H2944_204_0	6	5	Specialty Tier	3	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													713.00	25							724.00	25														25							25					25				25			25	2	3	
H2944	204	0	1	09	04	H2944_204_0	6	4	Non-Preferred Brand	1	4	110000	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													90.00	30		30					92.00	50		50												30		30					50		50			50				50			50			
H2944	204	0	1	09	04	H2944_204_0	6	3	Preferred Brand	1	4	000101	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													15.00	17		17					24.00	25		25												17		17					25		25			25				25			25			
H2944	204	0	1	09	04	H2944_204_0	6	2	Non-Preferred Generic	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										3.00		9.00						10.00		30.00													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H2944	204	0	1	09	04	H2944_204_0	6	5	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													614.00	25							623.00	25														25							25					25				25			25			
H2944	204	0	1	09	04	H2944_204_0	6	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										1.00		3.00						8.00		24.00													0.00		0.00					8.00		24.00				8.00					8.00			8.00				
H2944	204	0	1	09	04	H2944_204_0	6	2	Non-Preferred Generic	3	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										3.00		9.00						10.00		30.00													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	3	
H2944	220	0	1	09	04	H2944_220_0	6	3	Preferred Brand	1	3	000101		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		35.00		105.00																													35.00		95.00					35.00		105.00				35.00					35.00			35.00				
H2944	220	0	1	09	04	H2944_220_0	6	2	Non-Preferred Generic	1	3	000101		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		9.00		27.00																													0.00		0.00					9.00		27.00				9.00					9.00			9.00				
H2944	220	0	1	09	04	H2944_220_0	6	1	Preferred Generic	1	3	001010		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00				
H2944	220	0	1	09	04	H2944_220_0	6	4	Non-Preferred Brand	1	3	110000		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		70.00		210.00																													70.00		200.00					70.00		210.00				70.00					70.00			70.00				
H2944	220	0	1	09	04	H2944_220_0	6	5	Specialty Tier	1	3	010010		1	110000000010000100100101	30													30			30			30		31		31	14					614.00	25																														25							25					25				25			25			
H2949	012	0	1	01	01	H2949_012_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		1		
H2949	012	0	1	01	01	H2949_012_0	5	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					770.00	33																														33							33					33				33			33			
H2949	012	0	1	01	01	H2949_012_0	5	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H2949	012	0	1	01	01	H2949_012_0	5	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		38.00		114.00																													38.00		104.00					38.00		114.00				38.00					38.00			38.00				
H2949	012	0	1	01	01	H2949_012_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H2949	012	0	1	01	01	H2949_012_0	5	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		38.00		114.00																													38.00		104.00					38.00		114.00				38.00					38.00			38.00		2	2	
H2949	012	0	1	01	01	H2949_012_0	5	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H2949	012	0	1	01	01	H2949_012_0	5	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					912.00	33																														33							33					33				33			33	2	3	
H2949	013	0	1	01	01	H2949_013_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					320.00	33																														33							33					33				33			33			
H2949	013	0	1	01	01	H2949_013_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H2949	013	0	1	01	01	H2949_013_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H2949	013	0	1	01	01	H2949_013_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H2949	013	0	1	01	01	H2949_013_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H2949	013	0	1	01	01	H2949_013_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H2949	013	0	1	01	01	H2949_013_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					359.00	33																														33							33					33				33			33	2	1	
H2949	013	0	1	01	01	H2949_013_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H2949	013	0	1	01	01	H2949_013_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	3	
H2949	013	0	1	01	01	H2949_013_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	
H2949	014	0	1	01	01	H2949_014_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H2949	014	0	1	01	01	H2949_014_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H2949	014	0	1	01	01	H2949_014_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H2949	014	0	1	01	01	H2949_014_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H2949	014	0	1	01	01	H2949_014_0	4	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					981.00	33																														33							33					33				33			33	2	1	
H2949	014	0	1	01	01	H2949_014_0	4	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H2949	014	0	1	01	01	H2949_014_0	4	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	1	
H2949	014	0	1	01	01	H2949_014_0	4	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	
H2949	014	0	1	01	01	H2949_014_0	4	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H2949	014	0	1	01	01	H2949_014_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					871.00	33																														33							33					33				33			33			
H2960	004	0	1	01	01	H2960_004_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				3.00		7.50																								6.00																		3.00					3.00							
H2960	004	0	1	01	01	H2960_004_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				8.00		20.00																								16.00																		8.00					8.00							
H2960	004	0	1	01	01	H2960_004_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		45.00		112.50																								90.00																		45.00								45.00				
H2960	004	0	1	01	01	H2960_004_0	7	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				8.00		20.00																								16.00																		8.00					8.00					1		
H2960	004	0	1	01	01	H2960_004_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							1			90							30		31	14	31	14					264.00	33		33																							33																	33				33			33			
H2960	004	0	1	01	01	H2960_004_0	7	6	Select Diabetic Drugs	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		10.00		25.00																								20.00																		10.00								10.00				
H2960	004	0	1	01	01	H2960_004_0	7	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				3.00		7.50																								6.00																		3.00					3.00					1		
H2960	004	0	1	01	01	H2960_004_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		80.00		200.00																								160.00																		80.00								80.00				
H2960	010	0	1	01	01	H2960_010_0	6	6	Select Diabetic Drugs	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		20.00		50.00																								40.00																		20.00								20.00		1		
H2960	010	0	1	01	01	H2960_010_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				2.00		5.00																								4.00																		2.00					2.00							
H2960	010	0	1	01	01	H2960_010_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				4.00		10.00																								8.00																		4.00					4.00							
H2960	010	0	1	01	01	H2960_010_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		40.00		100.00																								80.00																		40.00								40.00				
H2960	010	0	1	01	01	H2960_010_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		70.00		175.00																								140.00																		70.00								70.00				
H2960	010	0	1	01	01	H2960_010_0	6	5	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							1			90							30		31	14	31	14					264.00	33		33																							33																	33				33			33			
H2960	010	0	1	01	01	H2960_010_0	6	6	Select Diabetic Drugs	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		10.00		25.00																								20.00																		10.00								10.00				
H2960	010	0	1	01	01	H2960_010_0	6	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				2.00		5.00																								4.00																		2.00					2.00					1		
H2960	010	0	1	01	01	H2960_010_0	6	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				4.00		10.00																								8.00																		4.00					4.00					1		
H2960	010	0	1	01	01	H2960_010_0	6	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		80.00		200.00																								160.00																		80.00								80.00		1		
H2960	012	0	1	01	01	H2960_012_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		45.00		112.50																								90.00																		45.00								45.00				
H2960	012	0	1	01	01	H2960_012_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				10.00		25.00																								20.00																		10.00					10.00							
H2960	012	0	1	01	01	H2960_012_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				4.00		10.00																								8.00																		4.00					4.00							
H2960	012	0	1	01	01	H2960_012_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		80.00		200.00																								160.00																		80.00								80.00				
H2960	012	0	1	01	01	H2960_012_0	6	5	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							1			90							30		31	14	31	14					264.00	33		33																							33																	33				33			33			
H2960	012	0	1	01	01	H2960_012_0	6	6	Select Diabetic Drugs	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		10.00		25.00																								20.00																		10.00								10.00				
H2960	012	0	1	01	01	H2960_012_0	6	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				4.00		10.00																								8.00																		4.00					4.00					1		
H2960	012	0	1	01	01	H2960_012_0	6	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				10.00		25.00																								20.00																		10.00					10.00					1		
H2960	018	0	1	01	01	H2960_018_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		45.00		112.50																								90.00																		45.00								45.00				
H2960	018	0	1	01	01	H2960_018_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				6.00		15.00																								12.00																		6.00					6.00							
H2960	018	0	1	01	01	H2960_018_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				2.00		5.00																								4.00																		2.00					2.00							
H2960	018	0	1	01	01	H2960_018_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		80.00		200.00																								160.00																		80.00								80.00				
H2960	018	0	1	01	01	H2960_018_0	6	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				6.00		15.00																								12.00																		6.00					6.00					1		
H2960	018	0	1	01	01	H2960_018_0	6	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				2.00		5.00																								4.00																		2.00					2.00					1		
H2960	018	0	1	01	01	H2960_018_0	6	6	Select Diabetic Drugs	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		10.00		25.00																								20.00																		10.00								10.00				
H2960	018	0	1	01	01	H2960_018_0	6	5	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							1			90							30		31	14	31	14					264.00	33		33																							33																	33				33			33			
H2962	001	0	1	01	01	H2962_001_0	7	2	Non-Preferred Generic	3	4	000100	1	2	011100000010001000000110	30	60	90							1			90							30		31	14				15.00	30.00	45.00																								45.00																		15.00					15.00					1		
H2962	001	0	1	01	01	H2962_001_0	7	1	Preferred Generic	3	4	001000	1	2	011100000010001000000110	30	60	90							1			90							30		31	14				0.00	0.00	0.00																								0.00																		0.00					0.00					1		
H2962	001	0	1	01	01	H2962_001_0	7	2	Non-Preferred Generic	1	4	000100	1	2	011100000010001000000110	30	60	90							1			90							30		31	14				15.00	30.00	45.00																								45.00																		15.00					15.00							
H2962	001	0	1	01	01	H2962_001_0	7	3	Preferred Brand	1	4	000001	1	2	111100000010001000000001	30	60	90							1			90							30				31	14		20.00	40.00	60.00																								60.00																		20.00								20.00				
H2962	001	0	1	01	01	H2962_001_0	7	4	Non-Preferred Brand	1	4	100000	1	2	111100000010001000000001	30	60	90							1			90							30				31	14		45.00	90.00	135.00																								135.00																		45.00								45.00				
H2962	001	0	1	01	01	H2962_001_0	7	5	Specialty Tier	1	4	010010	1	1	111100000010001000000111	30	60	90							1			90							30		31	14	31	14					333.33	33	33	33																							33																	33				33			33			
H2962	001	0	1	01	01	H2962_001_0	7	1	Preferred Generic	1	4	001000	1	2	011100000010001000000110	30	60	90							1			90							30		31	14				0.00	0.00	0.00																								0.00																		0.00					0.00							
H2962	002	0	1	01	01	H2962_002_0	10	2	Non-Preferred Generic	1	4	000100	1	2	011100000010001000000110	30	60	90							1			90							30		31	14				10.00	20.00	30.00																								30.00																		10.00					10.00							
H2962	002	0	1	01	01	H2962_002_0	10	2	Non-Preferred Generic	3	4	000100	1	2	011100000010001000000110	30	60	90							1			90							30		31	14				10.00	20.00	30.00																								30.00																		10.00					10.00					1		
H2962	002	0	1	01	01	H2962_002_0	10	1	Preferred Generic	3	4	001000	1	2	011100000010001000000110	30	60	90							1			90							30		31	14				0.00	0.00	0.00																								0.00																		0.00					0.00					1		
H2962	002	0	1	01	01	H2962_002_0	10	5	Specialty Tier	1	4	010010	1	1	111100000010001000000111	30	60	90							1			90							30		31	14	31	14					333.33	33	33	33																							33																	33				33			33			
H2962	002	0	1	01	01	H2962_002_0	10	4	Non-Preferred Brand	1	4	100000	1	2	111100000010001000000001	30	60	90							1			90							30				31	14		40.00	80.00	120.00																								120.00																		40.00								40.00				
H2962	002	0	1	01	01	H2962_002_0	10	3	Preferred Brand	1	4	000001	1	2	111100000010001000000001	30	60	90							1			90							30				31	14		15.00	30.00	45.00																								45.00																		15.00								15.00				
H2962	002	0	1	01	01	H2962_002_0	10	1	Preferred Generic	1	4	001000	1	2	011100000010001000000110	30	60	90							1			90							30		31	14				0.00	0.00	0.00																								0.00																		0.00					0.00							
H2997	007	0	1	04	01	H2997_007_0	14	1	Preferred Generic	1	3	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				4.00	8.00	12.00																						4.00	8.00	6.00																		4.00					4.00							
H2997	007	0	1	04	01	H2997_007_0	14	2	Non-Preferred Generic	1	3	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				9.00	18.00	27.00																						9.00	18.00	13.50																		9.00					9.00							
H2997	007	0	1	04	01	H2997_007_0	14	3	Preferred Brand	1	3	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		44.00	88.00	132.00																						44.00	88.00	110.00																		44.00					44.00			44.00				
H2997	007	0	1	04	01	H2997_007_0	14	6	Specialty Tier	1	3	010010		1	110000000010100000000111	30										30									30		34	14	34	14					878.00	33																							33																			33				33			33			
H2997	007	0	1	04	01	H2997_007_0	14	5	Injectable Drugs	1	3	010010		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H2997	007	0	1	04	01	H2997_007_0	14	4	Non-Preferred Brand	1	3	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H2997	008	0	1	04	01	H2997_008_0	15	4	Non-Preferred Brand	1	3	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		90.00	180.00	270.00																						90.00	180.00	225.00																		90.00					90.00			90.00				
H2997	008	0	1	04	01	H2997_008_0	15	6	Specialty Tier	1	3	010010		1	110000000010100000000111	30										30									30		34	14	34	14					577.00	33																							33																			33				33			33			
H2997	008	0	1	04	01	H2997_008_0	15	5	Injectable Drugs	1	3	010010		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H2997	008	0	1	04	01	H2997_008_0	15	3	Preferred Brand	1	3	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		43.00	86.00	129.00																						43.00	86.00	107.50																		43.00					43.00			43.00				
H2997	008	0	1	04	01	H2997_008_0	15	2	Non-Preferred Generic	1	3	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				10.00	20.00	30.00																						10.00	20.00	15.00																		10.00					10.00							
H2997	008	0	1	04	01	H2997_008_0	15	1	Preferred Generic	1	3	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				4.00	8.00	12.00																						4.00	8.00	6.00																		4.00					4.00							
H2997	009	0	1	04	01	H2997_009_0	15	4	Non-Preferred Brand	1	3	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		90.00	180.00	270.00																						90.00	180.00	225.00																		90.00					90.00			90.00				
H2997	009	0	1	04	01	H2997_009_0	15	6	Specialty Tier	1	3	010010		1	110000000010100000000111	30										30									30		34	14	34	14					577.00	33																							33																			33				33			33			
H2997	009	0	1	04	01	H2997_009_0	15	3	Preferred Brand	1	3	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		43.00	86.00	129.00																						43.00	86.00	107.50																		43.00					43.00			43.00				
H2997	009	0	1	04	01	H2997_009_0	15	2	Non-Preferred Generic	1	3	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				10.00	20.00	30.00																						10.00	20.00	15.00																		10.00					10.00							
H2997	009	0	1	04	01	H2997_009_0	15	1	Preferred Generic	1	3	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				4.00	8.00	12.00																						4.00	8.00	6.00																		4.00					4.00							
H2997	009	0	1	04	01	H2997_009_0	15	5	Injectable Drugs	1	3	010010		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H2997	010	0	1	04	01	H2997_010_0	16	5	Injectable Drugs	1	3	010010		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H2997	010	0	1	04	01	H2997_010_0	16	2	Non-Preferred Generic	1	3	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				10.00	20.00	30.00																						10.00	20.00	15.00																		10.00					10.00							
H2997	010	0	1	04	01	H2997_010_0	16	3	Preferred Brand	1	3	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		43.00	86.00	129.00																						43.00	86.00	107.50																		43.00					43.00			43.00				
H2997	010	0	1	04	01	H2997_010_0	16	4	Non-Preferred Brand	1	3	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		90.00	180.00	270.00																						90.00	180.00	225.00																		90.00					90.00			90.00				
H2997	010	0	1	04	01	H2997_010_0	16	6	Specialty Tier	1	3	010010		1	110000000010100000000111	30										30									30		34	14	34	14					577.00	33																							33																			33				33			33			
H2997	010	0	1	04	01	H2997_010_0	16	1	Preferred Generic	1	3	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				4.00	8.00	12.00																						4.00	8.00	6.00																		4.00					4.00							
H3028	001	0	1	01	01	H3028_001_0	10	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00				
H3028	001	0	1	01	01	H3028_001_0	10	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H3028	001	0	1	01	01	H3028_001_0	10	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		35.00		105.00																													35.00		95.00					35.00		105.00				35.00					35.00			35.00				
H3028	001	0	1	01	01	H3028_001_0	10	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		70.00		210.00																													70.00		200.00					70.00		210.00				70.00					70.00			70.00				
H3028	001	0	1	01	01	H3028_001_0	10	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					887.00	33																														33							33					33				33			33	2	3	
H3028	001	0	1	01	01	H3028_001_0	10	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00		2	3	1
H3028	001	0	1	01	01	H3028_001_0	10	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H3028	001	0	1	01	01	H3028_001_0	10	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		35.00		105.00																													35.00		95.00					35.00		105.00				35.00					35.00			35.00		2	2	
H3028	001	0	1	01	01	H3028_001_0	10	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		70.00		210.00																													70.00		200.00					70.00		210.00				70.00					70.00			70.00		2	3	
H3028	001	0	1	01	01	H3028_001_0	10	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					786.00	33																														33							33					33				33			33			
H3107	004	0	1	01	01	H3107_004_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H3107	004	0	1	01	01	H3107_004_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H3107	004	0	1	01	01	H3107_004_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H3107	004	0	1	01	01	H3107_004_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H3107	004	0	1	01	01	H3107_004_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					639.00	33		33																														33							33			33				33			33			
H3107	012	0	1	01	01	H3107_012_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															0.00							18.00				6.00					6.00							
H3107	012	0	1	01	01	H3107_012_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					682.00	33		33																														33							33			33				33			33			
H3107	012	0	1	01	01	H3107_012_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H3107	012	0	1	01	01	H3107_012_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H3107	012	0	1	01	01	H3107_012_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00							
H3132	001	0	1	01	01	H3132_001_0	7	3	Non-Preferred Brand	1	2	100000		1	110000000010000000000001	30																			30				34	14					2000.00	25																																										25							25			
H3132	001	0	1	01	01	H3132_001_0	7	2	Preferred Brand	1	2	010001		1	110100000010000000000111	30		90							1										30		34	14	34	14					2000.00	25		25																																								25				25			25			
H3132	001	0	1	01	01	H3132_001_0	7	1	Preferred Generic	1	2	001010		1	110100000010000000000111	30		90							1										30		34	14	34	14					2000.00	25		25																																								25				25			25			
H3144	001	0	1	01	01	H3144_001_0	10	3	Non-Preferred Brand	1	4	100100	1	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										80.00		240.00						95.00		285.00						80.00		240.00																		95.00					95.00			95.00				
H3144	001	0	1	01	01	H3144_001_0	10	2	Preferred Brand	1	4	000001	1	2	100010110110101000000001				30		90	30		90	2	30		90							30				31	14										40.00		120.00						45.00		135.00						40.00		120.00																		45.00								45.00				
H3144	001	0	1	01	01	H3144_001_0	10	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													866.39	33							866.39	33																										33				33			33			
H3144	001	0	1	01	01	H3144_001_0	10	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													5.00		15.00						8.00		24.00						5.00		15.00																		8.00					8.00							
H3144	002	0	1	01	01	H3144_002_0	8	2	Preferred Brand	1	4	000001	1	2	100010110110101000000001				30		90	30		90	2	30		90							30				31	14										40.00		120.00						45.00		135.00						40.00		120.00																		45.00								45.00				
H3144	002	0	1	01	01	H3144_002_0	8	3	Non-Preferred Brand	1	4	100100	1	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										80.00		240.00						95.00		285.00						80.00		240.00																		95.00					95.00			95.00				
H3144	002	0	1	01	01	H3144_002_0	8	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													5.00		15.00						8.00		24.00						5.00		15.00																		8.00					8.00							
H3144	002	0	1	01	01	H3144_002_0	8	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													866.39	33							866.39	33																										33				33			33			
H3144	003	0	1	01	01	H3144_003_0	8	2	Preferred Brand	1	4	000001	1	2	100010110110101000000001				30		90	30		90	2	30		90							30				31	14										40.00		120.00						45.00		135.00						40.00		120.00																		45.00								45.00				
H3144	003	0	1	01	01	H3144_003_0	8	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													5.00		15.00						8.00		24.00						5.00		15.00																		8.00					8.00							
H3144	003	0	1	01	01	H3144_003_0	8	3	Non-Preferred Brand	1	4	100100	1	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										80.00		240.00						95.00		285.00						80.00		240.00																		95.00					95.00			95.00				
H3144	003	0	1	01	01	H3144_003_0	8	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													866.39	33							866.39	33																										33				33			33			
H3152	022	0	1	01	01	H3152_022_0	7	4	Non-Preferred Brand	1	3	100000		2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H3152	022	0	1	01	01	H3152_022_0	7	5	Specialty Tier	1	3	010010		1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					202.73	25	25	25																												25	25	25					25	25	25				25			25			25			
H3152	022	0	1	01	01	H3152_022_0	7	1	Preferred Generic	1	3	001000		2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					4.00	8.00	12.00																													4.00	8.00	8.00					4.00	8.00	12.00					4.00				4.00							
H3152	022	0	1	01	01	H3152_022_0	7	2	Non-Preferred Generic	1	3	000100		2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H3152	022	0	1	01	01	H3152_022_0	7	3	Preferred Brand	1	3	000001		2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		41.00	82.00	123.00																													41.00	82.00	82.00					41.00	82.00	123.00					41.00							41.00				
H3152	046	0	1	01	01	H3152_046_0	5	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H3152	046	0	1	01	01	H3152_046_0	5	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					6.00	12.00	18.00																													6.00	12.00	12.00					6.00	12.00	18.00					6.00				6.00							
H3152	046	0	1	01	01	H3152_046_0	5	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H3152	046	0	1	01	01	H3152_046_0	5	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H3152	046	0	1	01	01	H3152_046_0	5	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					354.76	33	33	33																												33	33	33					33	33	33				33			33			33			
H3152	048	0	1	01	01	H3152_048_0	5	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					259.48	33	33	33																												33	33	33					33	33	33				33			33			33			
H3152	048	0	1	01	01	H3152_048_0	5	1	Preferred Generic	3	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					6.00	12.00	18.00																													6.00	12.00	12.00					6.00	12.00	18.00					6.00				6.00					1		
H3152	048	0	1	01	01	H3152_048_0	5	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H3152	048	0	1	01	01	H3152_048_0	5	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H3152	048	0	1	01	01	H3152_048_0	5	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H3152	048	0	1	01	01	H3152_048_0	5	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					6.00	12.00	18.00																													6.00	12.00	12.00					6.00	12.00	18.00					6.00				6.00							
H3152	077	0	1	01	01	H3152_077_0	5	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					323.86	33	33	33																												33	33	33					33	33	33				33			33			33			
H3152	077	0	1	01	01	H3152_077_0	5	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H3152	077	0	1	01	01	H3152_077_0	5	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H3152	077	0	1	01	01	H3152_077_0	5	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					6.00	12.00	18.00																													6.00	12.00	12.00					6.00	12.00	18.00					6.00				6.00							
H3152	077	0	1	01	01	H3152_077_0	5	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H3154	004	0	1	01	01	H3154_004_0	7	1	Preferred Generic	1	2	001000		2	011100000010111000000100	30	60	90							1	30	60	90							30		31					0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00							
H3154	004	0	1	01	01	H3154_004_0	7	2	Non-Preferred Generic	1	2	000100		2	011100000010111000000100	30	60	90							1	30	60	90							30		31					5.00	10.00	15.00																						2.50	5.00	7.50																		5.00					5.00							
H3154	004	0	1	01	01	H3154_004_0	7	3	Preferred Brand	1	2	000001		2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		42.00	84.00	126.00																						42.00	84.00	126.00																		42.00								42.00				
H3154	004	0	1	01	01	H3154_004_0	7	5	Specialty Tier	1	2	010010		1	110000000010000000000101	30																			30		31		31	14					25.00	25																																										25				25			25			
H3154	004	0	1	01	01	H3154_004_0	7	4	Non-Preferred Brand	1	2	100000		2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		84.00	168.00	252.00																						84.00	168.00	252.00																		84.00								84.00				
H3154	006	0	1	02	01	H3154_006_0	6	1	Preferred Generic	1	4	001000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00							
H3154	006	0	1	02	01	H3154_006_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					5.00	10.00	15.00																						2.50	5.00	7.50																		5.00					5.00							
H3154	006	0	1	02	01	H3154_006_0	6	3	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		40.00	80.00	120.00																						40.00	80.00	120.00																		40.00								40.00				
H3154	006	0	1	02	01	H3154_006_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		80.00	160.00	240.00																						80.00	160.00	240.00																		80.00								80.00				
H3154	006	0	1	02	01	H3154_006_0	6	2	Non-Preferred Generic	3	4	000100	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					5.00	10.00	15.00																						2.50	5.00	7.50																		5.00					5.00					1		
H3154	006	0	1	02	01	H3154_006_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					33.00	33																																										33				33			33			
H3154	006	0	1	02	01	H3154_006_0	6	1	Preferred Generic	3	4	001000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00					1		
H3154	012	0	1	02	01	H3154_012_0	7	1	Preferred Generic	1	2	001000		2	011100000010111000000100	30	60	90							1	30	60	90							30		31					0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00							
H3154	012	0	1	02	01	H3154_012_0	7	3	Preferred Brand	1	2	000001		2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		42.00	84.00	126.00																						42.00	84.00	126.00																		42.00								42.00				
H3154	012	0	1	02	01	H3154_012_0	7	2	Non-Preferred Generic	1	2	000100		2	011100000010111000000100	30	60	90							1	30	60	90							30		31					4.00	8.00	12.00																						2.00	4.00	6.00																		4.00					4.00							
H3154	012	0	1	02	01	H3154_012_0	7	5	Specialty Tier	1	2	010010		1	110000000010000000000101	30																			30		31		31	14					25.00	25																																										25				25			25			
H3154	012	0	1	02	01	H3154_012_0	7	4	Non-Preferred Brand	1	2	100000		2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		84.00	168.00	252.00																						84.00	168.00	252.00																		84.00								84.00				
H3154	016	0	1	01	01	H3154_016_0	8	1	Preferred Generic	3	4	001000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00					1		
H3154	016	0	1	01	01	H3154_016_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					33.00	33																																										33				33			33			
H3154	016	0	1	01	01	H3154_016_0	8	4	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		84.00	168.00	252.00																						84.00	164.00	252.00																		84.00								84.00				
H3154	016	0	1	01	01	H3154_016_0	8	3	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		42.00	84.00	126.00																						42.00	84.00	126.00																		42.00								42.00				
H3154	016	0	1	01	01	H3154_016_0	8	2	Non-Preferred Generic	3	4	000100	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					6.00	12.00	18.00																						3.00	6.00	9.00																		6.00					6.00					1		
H3154	016	0	1	01	01	H3154_016_0	8	1	Preferred Generic	1	4	001000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00							
H3154	016	0	1	01	01	H3154_016_0	8	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					6.00	12.00	18.00																						3.00	6.00	9.00																		6.00					6.00							
H3156	030	0	1	01	01	H3156_030_0	6	1	Generic	1	3	010000		2	010100000010001000000110	30		90							1			90							30		31	14				4.00		12.00																								8.00																		4.00					4.00							
H3156	030	0	1	01	01	H3156_030_0	6	2	Preferred Brand	1	3	000001		2	110100000010001000000001	30		90							1			90							30				31	14		45.00		135.00																								90.00																		45.00								45.00				
H3156	030	0	1	01	01	H3156_030_0	6	3	Non-Preferred Brand	1	3	100000		2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								170.00																		85.00								85.00				
H3156	030	0	1	01	01	H3156_030_0	6	4	Specialty Tier	1	3	100000		1	110100000010001000000001	30		90							1			90							30				31	14					325.98	25		25																							25																	25							25			
H3204	001	0	1	01	01	H3204_001_0	5	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				2.00		6.00																								4.00																		2.00					2.00							
H3204	001	0	1	01	01	H3204_001_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				8.00		24.00																								16.00																		8.00					8.00							
H3204	001	0	1	01	01	H3204_001_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000000000111	30																			30		31	14	31	14					1092.75	33																																										33				33			33			
H3204	001	0	1	01	01	H3204_001_0	5	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		80.00		240.00																								240.00																		80.00								80.00				
H3204	001	0	1	01	01	H3204_001_0	5	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		40.00		120.00																								100.00																		40.00								40.00				
H3204	007	0	1	01	01	H3204_007_0	5	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		80.00		240.00																								240.00																		80.00								80.00				
H3204	007	0	1	01	01	H3204_007_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000000000111	30																			30		31	14	31	14					1092.75	33																																										33				33			33			
H3204	007	0	1	01	01	H3204_007_0	5	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				2.00		6.00																								4.00																		2.00					2.00					1		
H3204	007	0	1	01	01	H3204_007_0	5	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				8.00		24.00																								16.00																		8.00					8.00					1		
H3204	007	0	1	01	01	H3204_007_0	5	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				2.00		6.00																								4.00																		2.00					2.00							
H3204	007	0	1	01	01	H3204_007_0	5	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		40.00		120.00																								100.00																		40.00								40.00				
H3204	007	0	1	01	01	H3204_007_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				8.00		24.00																								16.00																		8.00					8.00							
H3206	001	0	1	04	01	H3206_001_0	4	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				8.00		24.00																								16.00																		8.00					8.00							
H3206	001	0	1	04	01	H3206_001_0	4	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		40.00		120.00																								100.00																		40.00								40.00				
H3206	001	0	1	04	01	H3206_001_0	4	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		80.00		240.00																								240.00																		80.00								80.00				
H3206	001	0	1	04	01	H3206_001_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000000000111	30																			30		31	14	31	14					868.16	33																																										33				33			33			
H3206	001	0	1	04	01	H3206_001_0	4	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				2.00		6.00																								4.00																		2.00					2.00							
H3206	002	0	1	04	01	H3206_002_0	4	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				8.00		24.00																								16.00																		8.00					8.00					1		
H3206	002	0	1	04	01	H3206_002_0	4	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				2.00		6.00																								4.00																		2.00					2.00					1		
H3206	002	0	1	04	01	H3206_002_0	4	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				2.00		6.00																								4.00																		2.00					2.00							
H3206	002	0	1	04	01	H3206_002_0	4	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				8.00		24.00																								16.00																		8.00					8.00							
H3206	002	0	1	04	01	H3206_002_0	4	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		40.00		120.00																								100.00																		40.00								40.00				
H3206	002	0	1	04	01	H3206_002_0	4	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		80.00		240.00																								240.00																		80.00								80.00				
H3206	002	0	1	04	01	H3206_002_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000000000111	30																			30		31	14	31	14					868.16	33																																										33				33			33			
H3240	010	0	1	01	01	H3240_010_0	7	5	Specialty Tier	1	4	100100	1	1	111100000010111000000111	31	62	93							2	31	62	93							31		31	1	31	1					488.00	25	25	25																					25	25	25																	25				25			25			
H3240	010	0	1	01	01	H3240_010_0	7	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	31	62	93							2	31	62	93							31		31	1				0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00					1		
H3240	010	0	1	01	01	H3240_010_0	7	4	Non-Preferred Brand	1	4	100000	1	1	111100000010111000000001	31	62	93							2	31	62	93							31				31	1					50.00	25	25	25																					25	25	25																	25							25			
H3240	010	0	1	01	01	H3240_010_0	7	3	Preferred Brand	1	4	000001	1	1	111100000010111000000001	31	62	93							2	31	62	93							31				31	1					47.00	25	25	25																					25	25	25																	25							25			
H3240	010	0	1	01	01	H3240_010_0	7	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	31	62	93							2	31	62	93							31		31	1				4.00	8.00	12.00																						4.00	6.00	8.00																		4.00					4.00							
H3240	010	0	1	01	01	H3240_010_0	7	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	31	62	93							2	31	62	93							31		31	1				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	9	1	Preferred Generic	1	4	001000	1	2	010100000001001000000100	30		90							1			90								29	31					0.00		0.00																								0.00																			0.00				0.00							
H3251	002	0	1	01	01	H3251_002_0	9	2	Non-Preferred Generic	3	4	000100	1	2	010100000001001000000100	30		90							1			90								29	31					4.00		12.00																								12.00																			4.00				4.00					1		
H3251	002	0	1	01	01	H3251_002_0	9	1	Preferred Generic	3	4	001000	1	2	010100000001001000000100	30		90							1			90								29	31					0.00		0.00																								0.00																			0.00				0.00					1		
H3251	002	0	1	01	01	H3251_002_0	9	5	Specialty Tier	1	4	000010	1	4	110100000001001000000001	30		90							1			90								29			31	2		350.00		1050.00	33.00	33		33																				1050.00			33																350.00		33					350.00	33			
H3251	002	0	1	01	01	H3251_002_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000001001000000001	30		90							1			90								29			31	2		70.00		210.00																								210.00																			70.00							70.00				
H3251	002	0	1	01	01	H3251_002_0	9	3	Preferred Brand	1	4	000001	1	2	110100000001001000000001	30		90							1			90								29			31	2		30.00		90.00																								90.00																			30.00							30.00				
H3251	002	0	1	01	01	H3251_002_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000001001000000100	30		90							1			90								29	31					4.00		12.00																								12.00																			4.00				4.00							
H3251	021	0	1	02	01	H3251_021_0	9	1	Preferred Generic	1	4	001000	1	2	010100000001001000000100	30		90							1			90								29	31					0.00		0.00																								0.00																			0.00				0.00							
H3251	021	0	1	02	01	H3251_021_0	9	1	Preferred Generic	3	4	001000	1	2	010100000001001000000100	30		90							1			90								29	31					0.00		0.00																								0.00																			0.00				0.00					1		
H3251	021	0	1	02	01	H3251_021_0	9	5	Specialty Tier	1	4	000010	1	4	110100000001001000000001	30		90							1			90								29			31	2		350.00		1050.00	33.00	33		33																				1050.00			33																350.00		33					350.00	33			
H3251	021	0	1	02	01	H3251_021_0	9	2	Non-Preferred Generic	3	4	000100	1	2	010100000001001000000100	30		90							1			90								29	31					7.00		21.00																								7.00																			7.00				7.00					1		
H3251	021	0	1	02	01	H3251_021_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000001001000000001	30		90							1			90								29			31	2		70.00		210.00																								210.00																			70.00							70.00				
H3251	021	0	1	02	01	H3251_021_0	9	3	Preferred Brand	1	4	000001	1	2	110100000001001000000001	30		90							1			90								29			31	2		36.00		108.00																								108.00																			36.00							36.00				
H3251	021	0	1	02	01	H3251_021_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000001001000000100	30		90							1			90								29	31					7.00		21.00																								21.00																			7.00				7.00							
H3251	024	0	1	01	01	H3251_024_0	11	2	Non-Preferred Generic	3	4	000100	1	2	010100000001001000000100	30		90							1			90								29	31					7.00		21.00																								21.00																			7.00				7.00					1		
H3251	024	0	1	01	01	H3251_024_0	11	1	Preferred Generic	3	4	001000	1	2	010100000001001000000100	30		90							1			90								29	31					0.00		0.00																								0.00																			0.00				0.00					1		
H3251	024	0	1	01	01	H3251_024_0	11	5	Specialty Tier	1	4	000010	1	4	110100000001001000000001	30		90							1			90								29			31	2		350.00		1050.00	33.00	33		33																				1050.00			33																350.00		33					350.00	33			
H3251	024	0	1	01	01	H3251_024_0	11	3	Preferred Brand	1	4	000001	1	2	110100000001001000000001	30		90							1			90								29			31	2		36.00		108.00																								108.00																			36.00							36.00				
H3251	024	0	1	01	01	H3251_024_0	11	2	Non-Preferred Generic	1	4	000100	1	2	010100000001001000000100	30		90							1			90								29	31					7.00		21.00																								21.00																			7.00				7.00							
H3251	024	0	1	01	01	H3251_024_0	11	1	Preferred Generic	1	4	001000	1	2	010100000001001000000100	30		90							1			90								29	31					0.00		0.00																								0.00																			0.00				0.00							
H3251	024	0	1	01	01	H3251_024_0	11	4	Non-Preferred Brand	1	4	100000	1	2	110100000001001000000001	30		90							1			90								29			31	2		70.00		210.00																								210.00																			70.00							70.00				
H3251	026	0	1	01	01	H3251_026_0	10	2	Non-Preferred Generic	3	4	000100	1	2	010100000001001000000100	30		90							1			90								29	31					4.00		12.00																								12.00																			4.00				4.00					1		
H3251	026	0	1	01	01	H3251_026_0	10	1	Preferred Generic	3	4	001000	1	2	010100000001001000000100	30		90							1			90								29	31					0.00		0.00																								0.00																			0.00				0.00					1		
H3251	026	0	1	01	01	H3251_026_0	10	5	Specialty Tier	1	4	000010	1	1	110100000001001000000001	30		90							1			90								29			31	2					33.00	33		33																							33																		33						33			
H3251	026	0	1	01	01	H3251_026_0	10	4	Non-Preferred Brand	1	4	100000	1	2	110100000001001000000001	30		90							1			90								29			31	2		75.00		225.00																								225.00																			75.00							75.00				
H3251	026	0	1	01	01	H3251_026_0	10	1	Preferred Generic	1	4	001000	1	2	010100000001001000000100	30		90							1			90								29	31					0.00		0.00																								0.00																			0.00				0.00							
H3251	026	0	1	01	01	H3251_026_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000001001000000100	30		90							1			90								29	31					4.00		12.00																								12.00																			4.00				4.00							
H3251	026	0	1	01	01	H3251_026_0	10	3	Preferred Brand	1	4	000001	1	2	110100000001001000000001	30		90							1			90								29			31	2		36.00		108.00																								108.00																			36.00							36.00				
H3251	027	0	1	01	01	H3251_027_0	13	2	Non-Preferred Generic	1	2	000100		2	010100000001001000000100	30		90							1			90								29	31					6.50		19.50																								19.50																			6.50				6.50							
H3251	027	0	1	01	01	H3251_027_0	13	3	Preferred Brand	1	2	000001		2	110100000001001000000001	30		90							1			90								29			31	2		45.00		135.00																								135.00																			45.00							45.00				
H3251	027	0	1	01	01	H3251_027_0	13	4	Non-Preferred Brand	1	2	100000		2	110100000001001000000001	30		90							1			90								29			31	2		95.00		285.00																								285.00																			95.00							95.00				
H3251	027	0	1	01	01	H3251_027_0	13	5	Specialty Tier	1	2	000010		1	110100000001001000000001	30		90							1			90								29			31	2					25.00	25		25																							25																		25						25			
H3251	027	0	1	01	01	H3251_027_0	13	1	Preferred Generic	1	2	001000		2	010100000001001000000100	30		90							1			90								29	31					0.00		0.00																								0.00																			0.00				0.00							
H3305	011	0	1	02	01	H3305_011_0	6	5	Select Care Drugs	3	4	010010	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00		1		
H3305	011	0	1	02	01	H3305_011_0	6	5	Select Care Drugs	1	4	010010	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00				
H3305	011	0	1	02	01	H3305_011_0	6	4	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					33.00	33																							33																			33				33			33			
H3305	011	0	1	02	01	H3305_011_0	6	3	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		90.00		270.00																						90.00		180.00																		90.00					90.00			90.00				
H3305	011	0	1	02	01	H3305_011_0	6	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		35.00		105.00																						35.00		70.00																		35.00								35.00				
H3305	011	0	1	02	01	H3305_011_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00							
H3305	015	0	1	02	01	H3305_015_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00							
H3305	015	0	1	02	01	H3305_015_0	6	5	Select Care Drugs	3	4	010010	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00		1		
H3305	015	0	1	02	01	H3305_015_0	6	5	Select Care Drugs	1	4	010010	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00				
H3305	015	0	1	02	01	H3305_015_0	6	4	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					33.00	33																							33																			33				33			33			
H3305	015	0	1	02	01	H3305_015_0	6	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		35.00		105.00																						35.00		70.00																		35.00								35.00				
H3305	015	0	1	02	01	H3305_015_0	6	3	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		90.00		270.00																						90.00		180.00																		90.00					90.00			90.00				
H3307	002	0	1	01	01	H3307_002_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		92.00		276.00																															266.00							276.00				92.00					92.00			92.00				
H3307	002	0	1	01	01	H3307_002_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					676.00	33		33																														33							33			33				33			33			
H3307	002	0	1	01	01	H3307_002_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		44.00		132.00																															122.00							132.00				44.00					44.00			44.00				
H3307	002	0	1	01	01	H3307_002_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H3307	002	0	1	01	01	H3307_002_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H3307	012	0	1	01	01	H3307_012_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					814.00	33		33																														33							33			33				33			33			
H3307	012	0	1	01	01	H3307_012_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H3307	012	0	1	01	01	H3307_012_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H3307	012	0	1	01	01	H3307_012_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H3307	012	0	1	01	01	H3307_012_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H3307	015	0	1	01	01	H3307_015_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					2.00		6.00																															4.00							6.00				2.00					2.00							
H3307	015	0	1	01	01	H3307_015_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					4.00		12.00																															8.00							12.00				4.00					4.00							
H3307	015	0	1	01	01	H3307_015_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		44.00		132.00																															122.00							132.00				44.00					44.00			44.00				
H3307	015	0	1	01	01	H3307_015_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		92.00		276.00																															266.00							276.00				92.00					92.00			92.00				
H3307	015	0	1	01	01	H3307_015_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					467.00	33		33																														33							33			33				33			33			
H3312	002	0	1	01	01	H3312_002_0	5	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H3312	002	0	1	01	01	H3312_002_0	5	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					6.00	12.00	18.00																													6.00	12.00	12.00					6.00	12.00	18.00					6.00				6.00							
H3312	002	0	1	01	01	H3312_002_0	5	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H3312	002	0	1	01	01	H3312_002_0	5	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H3312	002	0	1	01	01	H3312_002_0	5	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					359.99	33	33	33																												33	33	33					33	33	33				33			33			33			
H3312	018	0	1	01	01	H3312_018_0	7	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					7.00	14.00	21.00																													7.00	14.00	14.00					7.00	14.00	21.00					7.00				7.00							
H3312	018	0	1	01	01	H3312_018_0	7	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H3312	018	0	1	01	01	H3312_018_0	7	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H3312	018	0	1	01	01	H3312_018_0	7	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H3312	018	0	1	01	01	H3312_018_0	7	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					444.13	33	33	33																												33	33	33					33	33	33				33			33			33			
H3312	025	0	1	01	01	H3312_025_0	7	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H3312	025	0	1	01	01	H3312_025_0	7	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					6.00	12.00	18.00																													6.00	12.00	12.00					6.00	12.00	18.00					6.00				6.00							
H3312	025	0	1	01	01	H3312_025_0	7	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H3312	025	0	1	01	01	H3312_025_0	7	1	Preferred Generic	3	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					6.00	12.00	18.00																													6.00	12.00	12.00					6.00	12.00	18.00					6.00				6.00					1		
H3312	025	0	1	01	01	H3312_025_0	7	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					313.61	33	33	33																												33	33	33					33	33	33				33			33			33			
H3312	025	0	1	01	01	H3312_025_0	7	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H3312	043	0	1	01	01	H3312_043_0	7	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H3312	043	0	1	01	01	H3312_043_0	7	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H3312	043	0	1	01	01	H3312_043_0	7	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H3312	043	0	1	01	01	H3312_043_0	7	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					6.00	12.00	18.00																													6.00	12.00	12.00					6.00	12.00	18.00					6.00				6.00							
H3312	043	0	1	01	01	H3312_043_0	7	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					265.44	33	33	33																												33	33	33					33	33	33				33			33			33			
H3312	048	0	1	01	01	H3312_048_0	7	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H3312	048	0	1	01	01	H3312_048_0	7	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H3312	048	0	1	01	01	H3312_048_0	7	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H3312	048	0	1	01	01	H3312_048_0	7	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					6.00	12.00	18.00																													6.00	12.00	12.00					6.00	12.00	18.00					6.00				6.00							
H3312	048	0	1	01	01	H3312_048_0	7	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					136.43	33	33	33																												33	33	33					33	33	33				33			33			33			
H3327	001	0	1	01	01	H3327_001_0	6	1	Generic	1	4	010000	1	2	010100000010001000000100	30		90							2			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H3327	001	0	1	01	01	H3327_001_0	6	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		45.00		135.00																								112.50																		45.00								45.00				
H3327	001	0	1	01	01	H3327_001_0	6	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							2			90							30				31	14		80.00		240.00																								200.00																		80.00								80.00				
H3327	001	0	1	01	01	H3327_001_0	6	4	Specialty Tier	1	4	010010	1	1	110100000010001000000101	30		90							2			90							30		31		31	14					364.00	33		33																							33																	33				33			33			
H3327	002	0	1	01	01	H3327_002_0	5	4	Specialty Tier	1	4	010010	1	1	110100000010001000000101	30		90							2			90							30		31		31	14					404.00	33		33																							33																	33				33			33			
H3327	002	0	1	01	01	H3327_002_0	5	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							2			90							30				31	14		80.00		240.00																								200.00																		80.00								80.00				
H3327	002	0	1	01	01	H3327_002_0	5	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		30.00		90.00																								75.00																		30.00								30.00				
H3327	002	0	1	01	01	H3327_002_0	5	1	Generic	1	4	010000	1	2	010100000010001000000100	30		90							2			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H3327	038	0	1	02	01	H3327_038_0	7	4	Specialty Tier	1	4	010010	1	1	110100000010001000000101	30		90							2			90							30		31		31	14					364.00	33		33																							33																	33				33			33			
H3327	038	0	1	02	01	H3327_038_0	7	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							2			90							30				31	14		80.00		240.00																								200.00																		80.00								80.00				
H3327	038	0	1	02	01	H3327_038_0	7	1	Generic	1	4	010000	1	2	010100000010001000000100	30		90							2			90							30		31					6.00		18.00																								15.00																		6.00					6.00							
H3327	038	0	1	02	01	H3327_038_0	7	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		40.00		120.00																								100.00																		40.00								40.00				
H3328	002	0	1	01	01	H3328_002_0	6	1	Preferred Generic	1	2	001000		2	010100000010001000000110	30		90							1			90							30		34	14				0.00		0.00																								0.00																		0.00					0.00							
H3328	002	0	1	01	01	H3328_002_0	6	2	Non-Preferred Generic	1	2	000100		2	010100000010001000000110	30		90							1			90							30		34	14				15.00		45.00																								30.00																		15.00					15.00							
H3328	002	0	1	01	01	H3328_002_0	6	3	Preferred Brand	1	2	000001		2	110100000010001000000001	30		90							1			90							30				34	14		35.00		105.00																								70.00																		35.00								35.00				
H3328	002	0	1	01	01	H3328_002_0	6	5	Specialty Tier	1	2	010010		1	110100000010001000000111	30		90							1			90							30		34	14	34	14					465.00	25		25																							25																	25				25			25			
H3328	002	0	1	01	01	H3328_002_0	6	4	Non-Preferred Brand	1	2	100100		2	110100000010001000000111	30		90							1			90							30		34	14	34	14		70.00		210.00																								140.00																		70.00					70.00			70.00				
H3328	003	0	1	02	01	H3328_003_0	6	2	Non-Preferred Generic	1	3	000100		2	010100000010001000000110	30		90							1			90							30		34	14				15.00		45.00																								30.00																		15.00					15.00							
H3328	003	0	1	02	01	H3328_003_0	6	3	Preferred Brand	1	3	000001		2	110100000010001000000001	30		90							1			90							30				34	14		35.00		105.00																								70.00																		35.00								35.00				
H3328	003	0	1	02	01	H3328_003_0	6	1	Preferred Generic	1	3	001000		2	010100000010001000000110	30		90							1			90							30		34	14				0.00		0.00																								0.00																		0.00					0.00							
H3328	003	0	1	02	01	H3328_003_0	6	4	Non-Preferred Brand	1	3	100100		2	110100000010001000000111	30		90							1			90							30		34	14	34	14		70.00		210.00																								140.00																		70.00					70.00			70.00				
H3328	003	0	1	02	01	H3328_003_0	6	5	Specialty Tier	1	3	010010		1	110100000010001000000111	30		90							1			90							30		34	14	34	14					684.00	25		25																							25																	25				25			25			
H3328	016	0	1	01	01	H3328_016_0	4	2	Non-Preferred Generic	1	2	000100		2	010100000010001000000110	30		90							1			90							30		34	14				15.00		45.00																								30.00																		15.00					15.00							
H3328	016	0	1	01	01	H3328_016_0	4	3	Preferred Brand	1	2	000001		2	110100000010001000000001	30		90							1			90							30				34	14		35.00		105.00																								70.00																		35.00								35.00				
H3328	016	0	1	01	01	H3328_016_0	4	4	Non-Preferred Brand	1	2	100100		2	110100000010001000000111	30		90							1			90							30		34	14	34	14		91.00		273.00																								182.00																		91.00					91.00			91.00				
H3328	016	0	1	01	01	H3328_016_0	4	5	Specialty Tier	1	2	010010		1	110100000010001000000111	30		90							1			90							30		34	14	34	14					392.00	25		25																							25																	25				25			25			
H3328	016	0	1	01	01	H3328_016_0	4	1	Preferred Generic	1	2	001000		2	010100000010001000000110	30		90							1			90							30		34	14				0.00		0.00																								0.00																		0.00					0.00							
H3328	017	0	1	01	01	H3328_017_0	9	5	Specialty Tier	1	3	010010		1	110100000010001000000101	30		90							1			90							30		34		34	14					691.00	25		25																							25																	25				25			25			
H3328	017	0	1	01	01	H3328_017_0	9	4	Non-Preferred Brand	1	3	100100		2	110100000010001000000101	30		90							1			90							30		34		34	14		95.00		285.00																								190.00																		95.00					95.00			95.00				
H3328	017	0	1	01	01	H3328_017_0	9	3	Preferred Brand	1	3	000001		2	110100000010001000000001	30		90							1			90							30				34	14		35.00		105.00																								70.00																		35.00								35.00				
H3328	017	0	1	01	01	H3328_017_0	9	2	Non-Preferred Generic	1	3	000100		2	010100000010001000000100	30		90							1			90							30		34					15.00		45.00																								30.00																		15.00					15.00							
H3328	017	0	1	01	01	H3328_017_0	9	1	Preferred Generic	1	3	001000		2	010100000010001000000100	30		90							1			90							30		34					0.00		0.00																								0.00																		0.00					0.00							
H3328	019	0	1	01	01	H3328_019_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				34	14		35.00		105.00																								70.00																		35.00								35.00				
H3328	019	0	1	01	01	H3328_019_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010001000000111	30		90							1			90							30		34	14	34	14		75.00		225.00																								150.00																		75.00					75.00			75.00				
H3328	019	0	1	01	01	H3328_019_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							1			90							30		34	14	34	14					684.00	33		33																							33																	33				33			33			
H3328	019	0	1	01	01	H3328_019_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							1			90							30		34	14				15.00		45.00																								30.00																		15.00					15.00							
H3328	019	0	1	01	01	H3328_019_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							1			90							30		34	14				0.00		0.00																								0.00																		0.00					0.00							
H3330	021	1	1	01	01	H3330_021_1	10	1	Preferred Generic	1	4	001000	1	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					5.00	10.00	10.00																						5.00	10.00	10.00																		5.00					5.00							
H3330	021	1	1	01	01	H3330_021_1	10	2	Preferred Brand	1	4	010001	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		35.00	70.00	70.00																						35.00	70.00	70.00																		35.00					35.00			35.00				
H3330	021	1	1	01	01	H3330_021_1	10	3	Non-Preferred Brand	1	4	100100	1	1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					82.70	50	50	50																					50	50	50																	50				50			50			
H3330	021	1	1	01	01	H3330_021_1	10	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					968.01	25	25	25																					25	25	25																	25				25			25			
H3330	021	2	1	01	01	H3330_021_2	10	2	Preferred Brand	1	4	010001	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		35.00	70.00	70.00																						35.00	70.00	70.00																		35.00					35.00			35.00				
H3330	021	2	1	01	01	H3330_021_2	10	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					968.01	25	25	25																					25	25	25																	25				25			25			
H3330	021	2	1	01	01	H3330_021_2	10	3	Non-Preferred Brand	1	4	100100	1	1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					82.70	50	50	50																					50	50	50																	50				50			50			
H3330	021	2	1	01	01	H3330_021_2	10	1	Preferred Generic	1	4	001000	1	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					5.00	10.00	10.00																						5.00	10.00	10.00																		5.00					5.00							
H3330	021	3	1	01	01	H3330_021_3	10	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					968.01	25	25	25																					25	25	25																	25				25			25			
H3330	021	3	1	01	01	H3330_021_3	10	3	Non-Preferred Brand	1	4	100100	1	1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					82.70	50	50	50																					50	50	50																	50				50			50			
H3330	021	3	1	01	01	H3330_021_3	10	2	Preferred Brand	1	4	010001	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		35.00	70.00	70.00																						35.00	70.00	70.00																		35.00					35.00			35.00				
H3330	021	3	1	01	01	H3330_021_3	10	1	Preferred Generic	1	4	001000	1	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					5.00	10.00	10.00																						5.00	10.00	10.00																		5.00					5.00							
H3330	029	0	1	01	01	H3330_029_0	14	4	Specialty Tier	1	2	010010		1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					785.30	25	25	25																					25	25	25																	25				25			25			
H3330	029	0	1	01	01	H3330_029_0	14	3	Non-Preferred Brand	1	2	100100		1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					62.16	30	30	30																					30	30	30																	30				30			30			
H3330	029	0	1	01	01	H3330_029_0	14	1	Preferred Generic	1	2	001000		2	011100000010111000000100	30	60	90							2	30	60	90							30		31					4.00	8.00	8.00																						4.00	8.00	8.00																		4.00					4.00							
H3330	029	0	1	01	01	H3330_029_0	14	2	Preferred Brand	1	2	010001		1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					43.21	25	25	25																					25	25	25																	25				25			25			
H3330	032	1	1	01	01	H3330_032_1	11	1	Preferred Generic	1	4	001000	1	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					5.00	10.00	10.00																						5.00	10.00	10.00																		5.00					5.00							
H3330	032	1	1	01	01	H3330_032_1	11	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					750.56	25	25	25																					25	25	25																	25				25			25			
H3330	032	1	1	01	01	H3330_032_1	11	2	Preferred Brand	1	4	010001	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		35.00	70.00	70.00																						35.00	70.00	70.00																		35.00					35.00			35.00				
H3330	032	1	1	01	01	H3330_032_1	11	3	Non-Preferred Brand	1	4	100100	1	1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					82.70	50	50	50																					50	50	50																	50				50			50			
H3330	032	2	1	01	01	H3330_032_2	12	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					750.56	25	25	25																					25	25	25																	25				25			25			
H3330	032	2	1	01	01	H3330_032_2	12	3	Non-Preferred Brand	1	4	100100	1	1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					82.70	50	50	50																					50	50	50																	50				50			50			
H3330	032	2	1	01	01	H3330_032_2	12	1	Preferred Generic	1	4	001000	1	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					5.00	10.00	10.00																						5.00	10.00	10.00																		5.00					5.00							
H3330	032	2	1	01	01	H3330_032_2	12	2	Preferred Brand	1	4	010001	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		35.00	70.00	70.00																						35.00	70.00	70.00																		35.00					35.00			35.00				
H3330	032	3	1	01	01	H3330_032_3	11	2	Preferred Brand	1	4	010001	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		35.00	70.00	70.00																						35.00	70.00	70.00																		35.00					35.00			35.00				
H3330	032	3	1	01	01	H3330_032_3	11	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					750.56	25	25	25																					25	25	25																	25				25			25			
H3330	032	3	1	01	01	H3330_032_3	11	3	Non-Preferred Brand	1	4	100100	1	1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					82.70	50	50	50																					50	50	50																	50				50			50			
H3330	032	3	1	01	01	H3330_032_3	11	1	Preferred Generic	1	4	001000	1	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					5.00	10.00	10.00																						5.00	10.00	10.00																		5.00					5.00							
H3330	033	1	1	01	01	H3330_033_1	10	3	Non-Preferred Brand	1	4	100100	1	1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					82.70	50	50	50																					50	50	50																	50				50			50			
H3330	033	1	1	01	01	H3330_033_1	10	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					750.56	25	25	25																					25	25	25																	25				25			25			
H3330	033	1	1	01	01	H3330_033_1	10	2	Preferred Brand	1	4	010001	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		35.00	70.00	70.00																						35.00	70.00	70.00																		35.00					35.00			35.00				
H3330	033	1	1	01	01	H3330_033_1	10	1	Preferred Generic	1	4	001000	1	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					5.00	10.00	10.00																						5.00	10.00	10.00																		5.00					5.00							
H3330	033	2	1	01	01	H3330_033_2	10	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					750.56	25	25	25																					25	25	25																	25				25			25			
H3330	033	2	1	01	01	H3330_033_2	10	3	Non-Preferred Brand	1	4	100100	1	1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					82.70	50	50	50																					50	50	50																	50				50			50			
H3330	033	2	1	01	01	H3330_033_2	10	2	Preferred Brand	1	4	010001	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		35.00	70.00	70.00																						35.00	70.00	70.00																		35.00					35.00			35.00				
H3330	033	2	1	01	01	H3330_033_2	10	1	Preferred Generic	1	4	001000	1	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					5.00	10.00	10.00																						5.00	10.00	10.00																		5.00					5.00							
H3330	033	3	1	01	01	H3330_033_3	10	1	Preferred Generic	1	4	001000	1	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					5.00	10.00	10.00																						5.00	10.00	10.00																		5.00					5.00							
H3330	033	3	1	01	01	H3330_033_3	10	2	Preferred Brand	1	4	010001	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		35.00	70.00	70.00																						35.00	70.00	70.00																		35.00					35.00			35.00				
H3330	033	3	1	01	01	H3330_033_3	10	3	Non-Preferred Brand	1	4	100100	1	1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					82.70	50	50	50																					50	50	50																	50				50			50			
H3330	033	3	1	01	01	H3330_033_3	10	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					750.56	25	25	25																					25	25	25																	25				25			25			
H3333	055	0	1	09	04	H3333_055_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		95.00		237.50																													95.00		190.00					95.00		237.50				95.00								95.00				
H3333	055	0	1	09	04	H3333_055_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		45.00		112.50																													45.00		90.00					45.00		112.50				45.00								45.00				
H3333	055	0	1	09	04	H3333_055_0	7	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		12.00		30.00																													12.00		24.00					12.00		30.00				12.00					12.00			12.00				
H3333	055	0	1	09	04	H3333_055_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					5.00		12.50																													5.00		10.00					5.00		12.50				5.00					5.00							
H3333	055	0	1	09	04	H3333_055_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					435.00	29																														29							29					29				29			29			
H3333	057	0	1	09	04	H3333_057_0	7	4	Non-Preferred Brand	1	3	100000		2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		95.00		237.50																													95.00		190.00					95.00		237.50				95.00								95.00				
H3333	057	0	1	09	04	H3333_057_0	7	3	Preferred Brand	1	3	000001		2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		45.00		112.50																													45.00		90.00					45.00		112.50				45.00								45.00				
H3333	057	0	1	09	04	H3333_057_0	7	2	Non-Preferred Generic	1	3	000110		2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		12.00		30.00																													12.00		24.00					12.00		30.00				12.00					12.00			12.00				
H3333	057	0	1	09	04	H3333_057_0	7	1	Preferred Generic	1	3	001000		2	010100000010000101101100	30		90							2				30		90	30		90	30		34					5.00		12.50																													5.00		10.00					5.00		12.50				5.00					5.00							
H3333	057	0	1	09	04	H3333_057_0	7	5	Specialty Tier	1	3	010010		1	110000000010000100100101	30													30			30			30		34		34	14					435.00	29																														29							29					29				29			29			
H3333	165	0	1	09	04	H3333_165_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					2.00		5.00																													2.00		4.00					2.00		5.00				2.00					2.00							
H3333	165	0	1	09	04	H3333_165_0	7	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		7.00		17.50																													7.00		14.00					7.00		17.50				7.00					7.00			7.00				
H3333	165	0	1	09	04	H3333_165_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		40.00		100.00																													40.00		80.00					40.00		100.00				40.00								40.00				
H3333	165	0	1	09	04	H3333_165_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		80.00		200.00																													80.00		160.00					80.00		200.00				80.00								80.00				
H3333	165	0	1	09	04	H3333_165_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					500.00	33																														33							33					33				33			33			
H3333	166	0	1	09	04	H3333_166_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					2.00		5.00																													2.00		4.00					2.00		5.00				2.00					2.00							
H3333	166	0	1	09	04	H3333_166_0	7	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		7.00		17.50																													7.00		14.00					7.00		17.50				7.00					7.00			7.00				
H3333	166	0	1	09	04	H3333_166_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		40.00		100.00																													40.00		80.00					40.00		100.00				40.00								40.00				
H3333	166	0	1	09	04	H3333_166_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		80.00		200.00																													80.00		160.00					80.00		200.00				80.00								80.00				
H3333	166	0	1	09	04	H3333_166_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					500.00	33																														33							33					33				33			33			
H3335	002	0	1	04	01	H3335_002_0	7	4	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							1			90							30		31	14	31	14					593.00	33		33																							33																	33				33			33			
H3335	002	0	1	04	01	H3335_002_0	7	3	Non-Preferred Brand	1	4	100000	3	2	110100000010001000000001	30		90							1			90							30				31	14		90.00		225.00																								225.00																		90.00								90.00				
H3335	002	0	1	04	01	H3335_002_0	7	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		40.00		100.00																								100.00																		40.00								40.00				
H3335	002	0	1	04	01	H3335_002_0	7	1	Generic	1	4	010000	3	2	010100000010001000000110	30		90							1			90							30		31	14				2.00		5.00																								5.00																		2.00					2.00							
H3335	005	0	1	04	01	H3335_005_0	6	1	Generic	1	4	010000	3	2	010100000010001000000110	30		90							1			90							30		31	14				5.00		12.50																								12.50																		5.00					5.00							
H3335	005	0	1	04	01	H3335_005_0	6	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		40.00		100.00																								100.00																		40.00								40.00				
H3335	005	0	1	04	01	H3335_005_0	6	3	Non-Preferred Brand	1	4	100000	3	2	110100000010001000000001	30		90							1			90							30				31	14		80.00		200.00																								200.00																		80.00								80.00				
H3335	005	0	1	04	01	H3335_005_0	6	4	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							1			90							30		31	14	31	14					1288.00	33		33																							33																	33				33			33			
H3335	006	0	1	04	01	H3335_006_0	6	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		40.00		100.00																								100.00																		40.00								40.00				
H3335	006	0	1	04	01	H3335_006_0	6	4	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							1			90							30		31	14	31	14					804.00	33		33																							33																	33				33			33			
H3335	006	0	1	04	01	H3335_006_0	6	3	Non-Preferred Brand	1	4	100000	3	2	110100000010001000000001	30		90							1			90							30				31	14		80.00		200.00																								200.00																		80.00								80.00				
H3335	006	0	1	04	01	H3335_006_0	6	1	Generic	1	4	010000	3	2	010100000010001000000110	30		90							1			90							30		31	14				5.00		12.50																								12.50																		5.00					5.00							
H3335	008	0	1	04	01	H3335_008_0	6	3	Non-Preferred Brand	1	4	100000	3	2	110100000010001000000001	30		90							1			90							30				31	14		80.00		200.00																								200.00																		80.00								80.00				
H3335	008	0	1	04	01	H3335_008_0	6	1	Generic	1	4	010000	3	2	010100000010001000000110	30		90							1			90							30		31	14				5.00		12.50																								12.50																		5.00					5.00							
H3335	008	0	1	04	01	H3335_008_0	6	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		40.00		100.00																								100.00																		40.00								40.00				
H3335	008	0	1	04	01	H3335_008_0	6	4	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							1			90							30		31	14	31	14					606.00	33		33																							33																	33				33			33			
H3335	009	0	1	04	01	H3335_009_0	6	1	Generic	1	4	010000	3	2	010100000010001000000110	30		90							1			90							30		31	14				5.00		12.50																								12.50																		5.00					5.00							
H3335	009	0	1	04	01	H3335_009_0	6	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		40.00		100.00																								100.00																		40.00								40.00				
H3335	009	0	1	04	01	H3335_009_0	6	3	Non-Preferred Brand	1	4	100000	3	2	110100000010001000000001	30		90							1			90							30				31	14		80.00		200.00																								200.00																		80.00								80.00				
H3335	009	0	1	04	01	H3335_009_0	6	4	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							1			90							30		31	14	31	14					807.00	33		33																							33																	33				33			33			
H3335	014	0	1	04	01	H3335_014_0	6	4	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							1			90							30		31	14	31	14					719.00	33		33																							33																	33				33			33			
H3335	014	0	1	04	01	H3335_014_0	6	1	Generic	1	4	010000	3	2	010100000010001000000110	30		90							1			90							30		31	14				5.00		12.50																								12.50																		5.00					5.00							
H3335	014	0	1	04	01	H3335_014_0	6	3	Non-Preferred Brand	1	4	100000	3	2	110100000010001000000001	30		90							1			90							30				31	14		80.00		200.00																								200.00																		80.00								80.00				
H3335	014	0	1	04	01	H3335_014_0	6	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		40.00		100.00																								100.00																		40.00								40.00				
H3335	015	0	1	04	01	H3335_015_0	6	3	Non-Preferred Brand	1	4	100000	3	2	110100000010001000000001	30		90							1			90							30				31	14		80.00		200.00																								200.00																		80.00								80.00				
H3335	015	0	1	04	01	H3335_015_0	6	4	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							1			90							30		31	14	31	14					736.00	33		33																							33																	33				33			33			
H3335	015	0	1	04	01	H3335_015_0	6	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		40.00		100.00																								100.00																		40.00								40.00				
H3335	015	0	1	04	01	H3335_015_0	6	1	Generic	1	4	010000	3	2	010100000010001000000110	30		90							1			90							30		31	14				5.00		12.50																								12.50																		5.00					5.00							
H3335	018	0	1	04	01	H3335_018_0	6	4	Specialty Tier	1	3	010010		1	110100000010001000000111	30		90							1			90							30		31	14	31	14					541.00	25		25																							25																	25				25			25			
H3335	018	0	1	04	01	H3335_018_0	6	3	Non-Preferred Brand	1	3	100000		2	110100000010001000000001	30		90							1			90							30				31	14		95.00		237.50																								237.50																		95.00								95.00				
H3335	018	0	1	04	01	H3335_018_0	6	1	Generic	1	3	010000	1	2	010100000010001000000110	30		90							1			90							30		31	14				8.00		20.00																								20.00																		8.00					8.00							
H3335	018	0	1	04	01	H3335_018_0	6	2	Preferred Brand	1	3	000001		2	110100000010001000000001	30		90							1			90							30				31	14		45.00		112.50																								112.50																		45.00								45.00				
H3335	021	0	1	04	01	H3335_021_0	6	2	Preferred Brand	1	3	000001		2	110100000010001000000001	30		90							1			90							30				31	14		45.00		112.50																								112.50																		45.00								45.00				
H3335	021	0	1	04	01	H3335_021_0	6	1	Generic	1	3	010000		2	010100000010001000000110	30		90							1			90							30		31	14				8.00		20.00																								20.00																		8.00					8.00							
H3335	021	0	1	04	01	H3335_021_0	6	3	Non-Preferred Brand	1	3	100000		2	110100000010001000000001	30		90							1			90							30				31	14		95.00		237.50																								237.50																		95.00								95.00				
H3335	021	0	1	04	01	H3335_021_0	6	4	Specialty Tier	1	3	010010		1	110100000010001000000111	30		90							1			90							30		31	14	31	14					260.00	25		25																							25																	25				25			25			
H3335	032	0	1	04	01	H3335_032_0	6	1	Generic	1	4	010000	3	2	010100000010001000000110	30		90							1			90							30		31	14				3.00		7.50																								7.50																		3.00					3.00							
H3335	032	0	1	04	01	H3335_032_0	6	4	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							1			90							30		31	14	31	14					631.00	33		33																							33																	33				33			33			
H3335	032	0	1	04	01	H3335_032_0	6	3	Non-Preferred Brand	1	4	100000	3	2	110100000010001000000001	30		90							1			90							30				31	14		90.00		225.00																								225.00																		90.00								90.00				
H3335	032	0	1	04	01	H3335_032_0	6	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		40.00		100.00																								100.00																		40.00								40.00				
H3335	037	0	1	04	01	H3335_037_0	6	3	Non-Preferred Brand	1	4	100000	3	2	110100000010001000000001	30		90							1			90							30				31	14		90.00		225.00																								225.00																		90.00								90.00				
H3335	037	0	1	04	01	H3335_037_0	6	1	Generic	1	4	010000	3	2	010100000010001000000110	30		90							1			90							30		31	14				6.00		15.00																								15.00																		6.00					6.00							
H3335	037	0	1	04	01	H3335_037_0	6	4	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							1			90							30		31	14	31	14					454.00	33		33																							33																	33				33			33			
H3335	037	0	1	04	01	H3335_037_0	6	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		45.00		112.50																								112.50																		45.00								45.00				
H3335	038	0	1	04	01	H3335_038_0	6	1	Generic	1	4	010000	3	2	010100000010001000000110	30		90							1			90							30		31	14				6.00		15.00																								15.00																		6.00					6.00							
H3335	038	0	1	04	01	H3335_038_0	6	3	Non-Preferred Brand	1	4	100000	3	2	110100000010001000000001	30		90							1			90							30				31	14		90.00		225.00																								225.00																		90.00								90.00				
H3335	038	0	1	04	01	H3335_038_0	6	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		45.00		112.50																								112.50																		45.00								45.00				
H3335	038	0	1	04	01	H3335_038_0	6	4	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							1			90							30		31	14	31	14					454.00	33		33																							33																	33				33			33			
H3335	051	0	1	04	01	H3335_051_0	7	1	Generic	1	4	010000	3	2	010100000010001000000110	30		90							1			90							30		31	14				6.00		15.00																								15.00																		6.00					6.00							
H3335	051	0	1	04	01	H3335_051_0	7	4	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							1			90							30		31	14	31	14					454.00	33		33																							33																	33				33			33			
H3335	051	0	1	04	01	H3335_051_0	7	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		45.00		112.50																								112.50																		45.00								45.00				
H3335	051	0	1	04	01	H3335_051_0	7	3	Non-Preferred Brand	1	4	100000	3	2	110100000010001000000001	30		90							1			90							30				31	14		90.00		225.00																								225.00																		90.00								90.00				
H3337	001	0	1	01	01	H3337_001_0	8	5	Specialty Tier	1	4	010010	3	1	110000000010100000000101	31										31									31		31		31	14					467.89	25																							25																			25				25			25			
H3337	001	0	1	01	01	H3337_001_0	8	1	Preferred Generic	3	4	001000	1	2	011100000010111000000100	31	62	92							1	31	62	92							31		31					0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00					1		
H3337	001	0	1	01	01	H3337_001_0	8	2	Non-Preferred Generic	3	4	000100	3	2	011100000010111000000100	31	62	92							1	31	62	92							31		31					10.00	20.00	30.00																						10.00	20.00	30.00																		10.00					10.00					1		
H3337	001	0	1	01	01	H3337_001_0	8	1	Preferred Generic	1	4	001000	1	2	011100000010111000000100	31	62	92							1	31	62	92							31		31					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	8	2	Non-Preferred Generic	1	4	000100	3	2	011100000010111000000100	31	62	92							1	31	62	92							31		31					10.00	20.00	30.00																						10.00	20.00	30.00																		10.00					10.00							
H3337	001	0	1	01	01	H3337_001_0	8	3	Preferred Brand	1	4	000001	1	2	111100000010111000000001	31	62	92							1	31	62	92							31				31	14		25.00	50.00	75.00																						25.00	50.00	75.00																		25.00								25.00				
H3337	001	0	1	01	01	H3337_001_0	8	4	Non-Preferred Brand	1	4	100000	3	2	111100000010111000000001	31	62	92							2	31	62	92							31				31	14		50.00	100.00	150.00																						50.00	100.00	150.00																		50.00								50.00				
H3342	001	0	1	04	01	H3342_001_0	10	5	Injectable Drugs	1	4	010010	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H3342	001	0	1	04	01	H3342_001_0	10	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H3342	001	0	1	04	01	H3342_001_0	10	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00					45.00			45.00				
H3342	001	0	1	04	01	H3342_001_0	10	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				8.00	16.00	24.00																						8.00	16.00	12.00																		8.00					8.00							
H3342	001	0	1	04	01	H3342_001_0	10	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				6.00	12.00	18.00																						6.00	12.00	9.00																		6.00					6.00							
H3342	001	0	1	04	01	H3342_001_0	10	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					777.00	33																							33																			33				33			33			
H3342	002	0	1	04	01	H3342_002_0	9	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				8.00	16.00	24.00																						8.00	16.00	12.00																		8.00					8.00							
H3342	002	0	1	04	01	H3342_002_0	9	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00					45.00			45.00				
H3342	002	0	1	04	01	H3342_002_0	9	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H3342	002	0	1	04	01	H3342_002_0	9	5	Injectable Drugs	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					100.00	33	33	33																					33	33	33																	33				33			33			
H3342	002	0	1	04	01	H3342_002_0	9	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					827.00	33																							33																			33				33			33			
H3342	002	0	1	04	01	H3342_002_0	9	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				6.00	12.00	18.00																						6.00	12.00	9.00																		6.00					6.00							
H3342	012	0	1	04	01	H3342_012_0	10	5	Injectable Drugs	1	4	010010	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H3342	012	0	1	04	01	H3342_012_0	10	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					860.00	33																							33																			33				33			33			
H3342	012	0	1	04	01	H3342_012_0	10	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H3342	012	0	1	04	01	H3342_012_0	10	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00					45.00			45.00				
H3342	012	0	1	04	01	H3342_012_0	10	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				14.00	28.00	42.00																						14.00	28.00	21.00																		14.00					14.00							
H3342	012	0	1	04	01	H3342_012_0	10	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				8.00	16.00	24.00																						8.00	16.00	12.00																		8.00					8.00							
H3342	013	0	1	04	01	H3342_013_0	11	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	14.00	10.50																		7.00					7.00							
H3342	013	0	1	04	01	H3342_013_0	11	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				10.00	20.00	30.00																						10.00	20.00	15.00																		10.00					10.00							
H3342	013	0	1	04	01	H3342_013_0	11	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00					45.00			45.00				
H3342	013	0	1	04	01	H3342_013_0	11	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H3342	013	0	1	04	01	H3342_013_0	11	5	Injectable Drugs	1	4	010010	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H3342	013	0	1	04	01	H3342_013_0	11	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					755.00	33																							33																			33				33			33			
H3342	014	0	1	04	01	H3342_014_0	11	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	14.00	10.50																		7.00					7.00							
H3342	014	0	1	04	01	H3342_014_0	11	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				10.00	20.00	30.00																						10.00	20.00	15.00																		10.00					10.00							
H3342	014	0	1	04	01	H3342_014_0	11	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00					45.00			45.00				
H3342	014	0	1	04	01	H3342_014_0	11	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H3342	014	0	1	04	01	H3342_014_0	11	5	Injectable Drugs	1	4	010010	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H3342	014	0	1	04	01	H3342_014_0	11	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					847.00	33																							33																			33				33			33			
H3342	015	0	1	04	01	H3342_015_0	11	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	14.00	10.50																		7.00					7.00							
H3342	015	0	1	04	01	H3342_015_0	11	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				10.00	20.00	30.00																						10.00	20.00	15.00																		10.00					10.00							
H3342	015	0	1	04	01	H3342_015_0	11	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00					45.00			45.00				
H3342	015	0	1	04	01	H3342_015_0	11	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H3342	015	0	1	04	01	H3342_015_0	11	5	Injectable Drugs	1	4	010010	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H3342	015	0	1	04	01	H3342_015_0	11	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					1060.00	33																							33																			33				33			33			
H3344	005	0	1	04	01	H3344_005_0	6	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							1			90							30		34	14				0.00		0.00																								0.00																		0.00					0.00					1		
H3344	005	0	1	04	01	H3344_005_0	6	2	Non-Preferred Generic	3	4	000110	1	2	110100000010001000000111	30		90							1			90							30		34	14	34	14		6.00		15.00																								15.00																		6.00					6.00			6.00		2	3	
H3344	005	0	1	04	01	H3344_005_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000000000111	30																			30		34	14	34	14					699.00	33																																										33				33			33			
H3344	005	0	1	04	01	H3344_005_0	6	4	Non-Preferred Brand	1	4	100100	3	2	110100000010001000000111	30		90							1			90							30		34	14	34	14		75.00		187.50																								187.50																		75.00				2.21	75.00		2.21	75.00				
H3344	005	0	1	04	01	H3344_005_0	6	3	Preferred Brand	1	4	000001	3	2	110100000010001000000001	30		90							1			90							30				34	14		42.00		105.00																								105.00																		42.00							1.24	42.00				
H3344	005	0	1	04	01	H3344_005_0	6	2	Non-Preferred Generic	1	4	000110	1	2	110100000010001000000111	30		90							1			90							30		34	14	34	14		6.00		15.00																								15.00																		6.00				.18	6.00		.18	6.00				
H3344	005	0	1	04	01	H3344_005_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							1			90							30		34	14				0.00		0.00																								0.00																		0.00				0.00	0.00							
H3344	006	0	1	04	01	H3344_006_0	9	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							1			90							30		34	14				0.00		0.00																								0.00																		0.00					0.00					1		
H3344	006	0	1	04	01	H3344_006_0	9	2	Non-Preferred Generic	1	4	000110	1	2	110100000010001000000111	30		90							1			90							30		34	14	34	14		6.00		15.00																								15.00																		6.00				.18	6.00		.18	6.00				
H3344	006	0	1	04	01	H3344_006_0	9	3	Preferred Brand	1	4	000001	3	2	110100000010001000000001	30		90							1			90							30				34	14		45.00		112.50																								112.50																		45.00							1.24	45.00				
H3344	006	0	1	04	01	H3344_006_0	9	4	Non-Preferred Brand	1	4	100100	3	2	110100000010001000000111	30		90							1			90							30		34	14	34	14		75.00		187.50																								187.50																		75.00				2.21	75.00		2.21	75.00				
H3344	006	0	1	04	01	H3344_006_0	9	2	Non-Preferred Generic	3	4	000110	1	2	110100000010001000000111	30		90							1			90							30		34	14	34	14		6.00		15.00																								15.00																		6.00					6.00			6.00		2	3	
H3344	006	0	1	04	01	H3344_006_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							1			90							30		34	14				0.00		0.00																								0.00																		0.00				0.00	0.00							
H3344	006	0	1	04	01	H3344_006_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010000000000111	30																			30		34	14	34	14					699.00	33																																										33				33			33			
H3347	005	0	1	01	01	H3347_005_0	10	4	Specialty Tier	1	2	010010		1	110100000010001000000111	30		90							2			90							30		31	14	31	14					402.00	25		25																							25																	25				25			25			
H3347	005	0	1	01	01	H3347_005_0	10	3	Non-Preferred Brand	1	2	110000		2	110100000010001000000111	30		90							2			90							30		31	14	31	14		90.00		270.00																								225.00																		90.00					90.00			90.00				
H3347	005	0	1	01	01	H3347_005_0	10	2	Preferred Brand	1	2	010001		2	110100000010001000000111	30		90							2			90							30		31	14	31	14		30.00		90.00																								75.00																		30.00					30.00			30.00				
H3347	005	0	1	01	01	H3347_005_0	10	1	Generic	1	2	010000		2	010100000010001000000110	30		90							2			90							30		31	14				4.00		12.00																								10.00																		4.00					4.00							
H3351	002	0	1	02	01	H3351_002_0	8	1	Generic	1	4	010000	3	2	010100000010001000000110	30		90							1			90							30		31	14				2.00		5.00																								5.00																		2.00					2.00							
H3351	002	0	1	02	01	H3351_002_0	8	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		40.00		100.00																								100.00																		40.00								40.00				
H3351	002	0	1	02	01	H3351_002_0	8	4	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							1			90							30		31	14	31	14					629.00	33		33																							33																	33				33			33			
H3351	002	0	1	02	01	H3351_002_0	8	3	Non-Preferred Brand	1	4	100000	3	2	110100000010001000000001	30		90							1			90							30				31	14		90.00		225.00																								225.00																		90.00								90.00				
H3351	006	0	1	02	01	H3351_006_0	7	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		40.00		100.00																								100.00																		40.00								40.00				
H3351	006	0	1	02	01	H3351_006_0	7	3	Non-Preferred Brand	1	4	100000	3	2	110100000010001000000001	30		90							1			90							30				31	14		90.00		225.00																								225.00																		90.00								90.00				
H3351	006	0	1	02	01	H3351_006_0	7	4	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							1			90							30		31	14	31	14					605.00	33		33																							33																	33				33			33			
H3351	006	0	1	02	01	H3351_006_0	7	1	Generic	1	4	010000	3	2	010100000010001000000110	30		90							1			90							30		31	14				3.00		7.50																								7.50																		3.00					3.00							
H3351	010	0	1	01	01	H3351_010_0	6	4	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							1			90							30		31	14	31	14					815.00	33		33																							33																	33				33			33			
H3351	010	0	1	01	01	H3351_010_0	6	3	Non-Preferred Brand	1	4	100000	3	2	110100000010001000000001	30		90							1			90							30				31	14		90.00		225.00																								225.00																		90.00								90.00				
H3351	010	0	1	01	01	H3351_010_0	6	1	Generic	1	4	010000	3	2	010100000010001000000110	30		90							1			90							30		31	14				2.00		5.00																								5.00																		2.00					2.00							
H3351	010	0	1	01	01	H3351_010_0	6	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		40.00		100.00																								100.00																		40.00								40.00				
H3351	011	0	1	01	01	H3351_011_0	6	4	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							1			90							30		31	14	31	14					589.00	33		33																							33																	33				33			33			
H3351	011	0	1	01	01	H3351_011_0	6	3	Non-Preferred Brand	1	4	100000	3	2	110100000010001000000001	30		90							1			90							30				31	14		90.00		225.00																								225.00																		90.00								90.00				
H3351	011	0	1	01	01	H3351_011_0	6	1	Generic	1	4	010000	3	2	010100000010001000000110	30		90							1			90							30		31	14				3.00		7.50																								7.50																		3.00					3.00							
H3351	011	0	1	01	01	H3351_011_0	6	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		40.00		100.00																								100.00																		40.00								40.00				
H3351	012	0	1	01	01	H3351_012_0	7	4	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							1			90							30		31	14	31	14					525.00	33		33																							33																	33				33			33			
H3351	012	0	1	01	01	H3351_012_0	7	3	Non-Preferred Brand	1	4	100000	3	2	110100000010001000000001	30		90							1			90							30				31	14		90.00		225.00																								225.00																		90.00								90.00				
H3351	012	0	1	01	01	H3351_012_0	7	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		40.00		100.00																								100.00																		40.00								40.00				
H3351	012	0	1	01	01	H3351_012_0	7	1	Generic	1	4	010000	3	2	010100000010001000000110	30		90							1			90							30		31	14				2.00		5.00																								5.00																		2.00					2.00							
H3351	013	0	1	01	01	H3351_013_0	6	4	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							1			90							30		31	14	31	14					709.00	33		33																							33																	33				33			33			
H3351	013	0	1	01	01	H3351_013_0	6	3	Non-Preferred Brand	1	4	100000	3	2	110100000010001000000001	30		90							1			90							30				31	14		90.00		225.00																								225.00																		90.00								90.00				
H3351	013	0	1	01	01	H3351_013_0	6	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		40.00		100.00																								100.00																		40.00								40.00				
H3351	013	0	1	01	01	H3351_013_0	6	1	Generic	1	4	010000	3	2	010100000010001000000110	30		90							1			90							30		31	14				3.00		7.50																								7.50																		3.00					3.00							
H3359	001	0	1	01	01	H3359_001_0	8	4	Specialty Tier	1	4	010010	1	1	110100000010001000000101	30		90							1			90							30		31		31	14					598.00	33		33																							33																	33				33			33			
H3359	001	0	1	01	01	H3359_001_0	8	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		40.00		120.00																								100.00																		40.00								40.00				
H3359	001	0	1	01	01	H3359_001_0	8	1	Generic	1	4	010000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H3359	001	0	1	01	01	H3359_001_0	8	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		80.00		240.00																								200.00																		80.00								80.00				
H3359	032	0	1	01	01	H3359_032_0	9	1	Generic	1	4	010000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H3359	032	0	1	01	01	H3359_032_0	9	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		40.00		120.00																								100.00																		40.00								40.00				
H3359	032	0	1	01	01	H3359_032_0	9	1	Generic	3	4	010000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H3359	032	0	1	01	01	H3359_032_0	9	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		80.00		240.00																								200.00																		80.00								80.00				
H3359	032	0	1	01	01	H3359_032_0	9	4	Specialty Tier	1	4	010010	1	1	110100000010001000000101	30		90							1			90							30		31		31	14					598.00	33		33																							33																	33				33			33			
H3361	043	0	1	01	01	H3361_043_0	6	3	Non-Preferred Brand	1	4	100000	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		95.00	190.00	285.00																													95.00	190.00	190.00							285.00				95.00								95.00				
H3361	043	0	1	01	01	H3361_043_0	6	2	Preferred Brand	1	4	000001	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		45.00	90.00	135.00																													45.00	90.00	90.00							135.00				45.00								45.00				
H3361	043	0	1	01	01	H3361_043_0	6	1	Generic	1	4	010010	3	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
H3361	043	0	1	01	01	H3361_043_0	6	4	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					707.00	25																														25							25					25							25			
H3361	065	0	1	01	01	H3361_065_0	7	4	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					707.00	25																														25							25					25							25			
H3361	065	0	1	01	01	H3361_065_0	7	3	Non-Preferred Brand	1	4	100000	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		95.00	190.00	285.00																													95.00	190.00	190.00							285.00				95.00								95.00				
H3361	065	0	1	01	01	H3361_065_0	7	2	Preferred Brand	1	4	000001	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		45.00	90.00	135.00																													45.00	90.00	90.00							135.00				45.00								45.00				
H3361	065	0	1	01	01	H3361_065_0	7	1	Generic	1	4	010010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
H3361	098	0	1	01	01	H3361_098_0	6	1	Generic	1	4	010010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
H3361	098	0	1	01	01	H3361_098_0	6	2	Preferred Brand	1	4	000001	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		45.00	90.00	135.00																													45.00	90.00	90.00							135.00				45.00								45.00				
H3361	098	0	1	01	01	H3361_098_0	6	3	Non-Preferred Brand	1	4	100000	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		95.00	190.00	285.00																													95.00	190.00	190.00							285.00				95.00								95.00				
H3361	098	0	1	01	01	H3361_098_0	6	4	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					707.00	25																														25							25					25							25			
H3361	099	0	1	02	01	H3361_099_0	8	1	Generic	1	4	010010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		3.00	6.00	9.00																													3.00	6.00	0.00							9.00				3.00					3.00			3.00				
H3361	099	0	1	02	01	H3361_099_0	8	2	Preferred Brand	1	4	000001	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		39.00	78.00	117.00																													39.00	78.00	78.00							117.00				39.00								39.00				
H3361	099	0	1	02	01	H3361_099_0	8	4	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
H3361	099	0	1	02	01	H3361_099_0	8	3	Non-Preferred Brand	1	4	100000	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		79.00	158.00	237.00																													79.00	158.00	158.00							237.00				79.00								79.00				
H3361	105	0	1	01	01	H3361_105_0	6	2	Preferred Brand	1	4	000001	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		45.00	90.00	135.00																													45.00	90.00	90.00							135.00				45.00								45.00				
H3361	105	0	1	01	01	H3361_105_0	6	1	Generic	1	4	010010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
H3361	105	0	1	01	01	H3361_105_0	6	4	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					707.00	25																														25							25					25							25			
H3361	105	0	1	01	01	H3361_105_0	6	3	Non-Preferred Brand	1	4	100000	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		95.00	190.00	285.00																													95.00	190.00	190.00							285.00				95.00								95.00				
H3361	106	0	1	02	01	H3361_106_0	6	2	Preferred Brand	1	4	000001	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		39.00	78.00	117.00																													39.00	78.00	78.00							117.00				39.00								39.00				
H3361	106	0	1	02	01	H3361_106_0	6	3	Non-Preferred Brand	1	4	100000	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		79.00	158.00	237.00																													79.00	158.00	158.00							237.00				79.00								79.00				
H3361	106	0	1	02	01	H3361_106_0	6	1	Generic	1	4	010010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
H3361	106	0	1	02	01	H3361_106_0	6	4	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
H3361	109	0	1	01	01	H3361_109_0	6	4	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					707.00	25																														25							25					25							25			
H3361	109	0	1	01	01	H3361_109_0	6	1	Generic	1	4	010010	3	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
H3361	109	0	1	01	01	H3361_109_0	6	3	Non-Preferred Brand	1	4	100000	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		95.00	190.00	285.00																													95.00	190.00	190.00							285.00				95.00								95.00				
H3361	109	0	1	01	01	H3361_109_0	6	2	Preferred Brand	1	4	000001	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		45.00	90.00	135.00																													45.00	90.00	90.00							135.00				45.00								45.00				
H3361	129	0	1	02	01	H3361_129_0	6	1	Generic	1	4	010010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
H3361	129	0	1	02	01	H3361_129_0	6	3	Non-Preferred Brand	1	4	100000	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		79.00	158.00	237.00																													79.00	158.00	158.00							237.00				79.00								79.00				
H3361	129	0	1	02	01	H3361_129_0	6	4	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
H3361	129	0	1	02	01	H3361_129_0	6	2	Preferred Brand	1	4	000001	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		39.00	78.00	117.00																													39.00	78.00	78.00							117.00				39.00								39.00				
H3361	130	0	1	01	01	H3361_130_0	6	2	Preferred Brand	1	4	000001	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		35.00	70.00	105.00																													35.00	70.00	70.00							105.00				35.00								35.00				
H3361	130	0	1	01	01	H3361_130_0	6	4	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
H3361	130	0	1	01	01	H3361_130_0	6	3	Non-Preferred Brand	1	4	100000	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		79.00	158.00	237.00																													79.00	158.00	158.00							237.00				79.00								79.00				
H3361	130	0	1	01	01	H3361_130_0	6	1	Generic	1	4	010010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		8.00	16.00	24.00																													8.00	16.00	0.00							24.00				8.00					8.00			8.00				
H3362	017	0	1	01	01	H3362_017_0	11	2	Non-Preferred Generic	3	4	000110	1	2	110100000010001000000111	30		90							1			90							30		34	14	34	14		5.00		12.50																								12.50																		5.00					5.00			5.00		2	3	
H3362	017	0	1	01	01	H3362_017_0	11	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							1			90							30		34	14				0.00		0.00																								0.00																		0.00					0.00					1		
H3362	017	0	1	01	01	H3362_017_0	11	5	Specialty Tier	1	4	010010	1	1	110000000010000000000111	30																			30		34	14	34	14					699.00	33																																										33				33			33			
H3362	017	0	1	01	01	H3362_017_0	11	4	Non-Preferred Brand	1	4	100100	3	2	110100000010001000000111	30		90							1			90							30		34	14	34	14		75.00		187.50																								187.50																		75.00				2.21	75.00		2.21	75.00				
H3362	017	0	1	01	01	H3362_017_0	11	3	Preferred Brand	1	4	000001	3	2	110100000010001000000001	30		90							1			90							30				34	14		45.00		112.50																								112.50																		45.00							1.32	45.00				
H3362	017	0	1	01	01	H3362_017_0	11	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							1			90							30		34	14				0.00		0.00																								0.00																		0.00				0.00	0.00							
H3362	017	0	1	01	01	H3362_017_0	11	2	Non-Preferred Generic	1	4	000110	1	2	110100000010001000000111	30		90							1			90							30		34	14	34	14		5.00		12.50																								15.00																		5.00				.15	5.00		.15	5.00				
H3362	020	0	1	01	01	H3362_020_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		34					0.00		0.00																								0.00																		0.00					0.00							
H3362	020	0	1	01	01	H3362_020_0	8	2	Non-Preferred Generic	1	4	000110	1	2	110100000010001000000111	30		90							1			90							30		34	14	34	14		5.00		12.50																								12.50																		5.00					5.00			5.00				
H3362	020	0	1	01	01	H3362_020_0	8	3	Preferred Brand	1	4	000001	3	1	110100000010001000000001	30		90							1			90							30				34	14					57.00	25		25																							25																	25							25			
H3362	020	0	1	01	01	H3362_020_0	8	4	Non-Preferred Brand	1	4	100100	3	1	110100000010001000000111	30		90							1			90							30		34	14	34	14					44.00	25		25																							25																	25				25			25			
H3362	020	0	1	01	01	H3362_020_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010000000000111	30																			30		34	14	34	14					529.00	25																																										25				25			25			
H3362	020	0	1	01	01	H3362_020_0	8	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		34					0.00		0.00																								0.00																		0.00					0.00					1		
H3362	020	0	1	01	01	H3362_020_0	8	2	Non-Preferred Generic	3	4	000110	1	2	110100000010001000000111	30		90							1			90							30		34	14	34	14		5.00		12.50																								12.50																		5.00					5.00			5.00		2	3	
H3362	026	0	1	02	01	H3362_026_0	11	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							1			90							30		34	14				0.00		0.00																								0.00																		0.00				0.00	0.00							
H3362	026	0	1	02	01	H3362_026_0	11	2	Non-Preferred Generic	1	4	000110	1	2	110100000010001000000111	30		90							1			90							30		34	14	34	14		5.00		12.50																								12.50																		5.00				.15	5.00		.15	5.00				
H3362	026	0	1	02	01	H3362_026_0	11	3	Preferred Brand	1	4	000001	3	2	110100000010001000000001	30		90							1			90							30				34	14		45.00		112.50																								112.50																		45.00							1.32	45.00				
H3362	026	0	1	02	01	H3362_026_0	11	4	Non-Preferred Brand	1	4	100100	3	2	110100000010001000000111	30		90							1			90							30		34	14	34	14		90.00		225.00																								225.00																		90.00				2.65	90.00		2.65	90.00				
H3362	026	0	1	02	01	H3362_026_0	11	5	Specialty Tier	1	4	010010	1	1	110000000010000000000111	30																			30		34	14	34	14					699.00	33																																										33				33			33			
H3362	026	0	1	02	01	H3362_026_0	11	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							1			90							30		34	14				0.00		0.00																								0.00																		0.00					0.00					1		
H3362	026	0	1	02	01	H3362_026_0	11	2	Non-Preferred Generic	3	4	000110	1	2	110100000010001000000111	30		90							1			90							30		34	14	34	14		5.00		12.50																								12.50																		5.00					5.00			5.00		2	3	
H3370	001	0	1	01	01	H3370_001_0	10	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				6.00	12.00	18.00																						6.00	12.00	9.00																		6.00					6.00							
H3370	001	0	1	01	01	H3370_001_0	10	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					882.00	33																							33																			33				33			33			
H3370	001	0	1	01	01	H3370_001_0	10	5	Injectable Drugs	1	4	010010	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H3370	001	0	1	01	01	H3370_001_0	10	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H3370	001	0	1	01	01	H3370_001_0	10	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00					45.00			45.00				
H3370	001	0	1	01	01	H3370_001_0	10	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				10.00	20.00	30.00																						10.00	20.00	15.00																		10.00					10.00							
H3370	002	0	1	01	01	H3370_002_0	8	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				10.00	20.00	30.00																						10.00	20.00	15.00																		10.00					10.00							
H3370	002	0	1	01	01	H3370_002_0	8	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				6.00	12.00	18.00																						6.00	12.00	9.00																		6.00					6.00							
H3370	002	0	1	01	01	H3370_002_0	8	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00					45.00			45.00				
H3370	002	0	1	01	01	H3370_002_0	8	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H3370	002	0	1	01	01	H3370_002_0	8	5	Injectable Drugs	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					88.00	33	33	33																					33	33	33																	33				33			33			
H3370	002	0	1	01	01	H3370_002_0	8	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					909.00	33																							33																			33				33			33			
H3370	003	0	1	01	01	H3370_003_0	8	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				6.00	12.00	18.00																						6.00	12.00	9.00																		6.00					6.00							
H3370	003	0	1	01	01	H3370_003_0	8	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				12.00	24.00	36.00																						12.00	24.00	18.00																		12.00					12.00							
H3370	003	0	1	01	01	H3370_003_0	8	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00					45.00			45.00				
H3370	003	0	1	01	01	H3370_003_0	8	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H3370	003	0	1	01	01	H3370_003_0	8	5	Injectable Drugs	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					71.00	33	33	33																					33	33	33																	33				33			33			
H3370	003	0	1	01	01	H3370_003_0	8	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					892.00	33																							33																			33				33			33			
H3370	004	0	1	01	01	H3370_004_0	8	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					954.00	33																							33																			33				33			33			
H3370	004	0	1	01	01	H3370_004_0	8	5	Injectable Drugs	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					99.00	33	33	33																					33	33	33																	33				33			33			
H3370	004	0	1	01	01	H3370_004_0	8	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H3370	004	0	1	01	01	H3370_004_0	8	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00					45.00			45.00				
H3370	004	0	1	01	01	H3370_004_0	8	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				10.00	20.00	30.00																						10.00	20.00	15.00																		10.00					10.00							
H3370	004	0	1	01	01	H3370_004_0	8	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				6.00	12.00	18.00																						6.00	12.00	9.00																		6.00					6.00							
H3370	014	0	1	01	01	H3370_014_0	11	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				10.00	20.00	30.00																						10.00	20.00	15.00																		10.00					10.00							
H3370	014	0	1	01	01	H3370_014_0	11	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00					45.00			45.00				
H3370	014	0	1	01	01	H3370_014_0	11	5	Injectable Drugs	1	4	010010	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H3370	014	0	1	01	01	H3370_014_0	11	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H3370	014	0	1	01	01	H3370_014_0	11	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				6.00	12.00	18.00																						6.00	12.00	9.00																		6.00					6.00							
H3370	014	0	1	01	01	H3370_014_0	11	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					885.00	33																							33																			33				33			33			
H3370	022	0	1	01	01	H3370_022_0	10	5	Injectable Drugs	1	4	010010	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H3370	022	0	1	01	01	H3370_022_0	10	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					1005.00	33																							33																			33				33			33			
H3370	022	0	1	01	01	H3370_022_0	10	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H3370	022	0	1	01	01	H3370_022_0	10	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				10.00	20.00	30.00																						10.00	20.00	15.00																		10.00					10.00							
H3370	022	0	1	01	01	H3370_022_0	10	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				6.00	12.00	18.00																						6.00	12.00	9.00																		6.00					6.00							
H3370	022	0	1	01	01	H3370_022_0	10	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00					45.00			45.00				
H3370	024	0	1	01	01	H3370_024_0	10	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								87.50																		35.00								35.00				
H3370	024	0	1	01	01	H3370_024_0	10	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H3370	024	0	1	01	01	H3370_024_0	10	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H3370	024	0	1	01	01	H3370_024_0	10	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		10.00		30.00																								25.00																		10.00								10.00				
H3370	024	0	1	01	01	H3370_024_0	10	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H3370	024	0	1	01	01	H3370_024_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H3370	024	0	1	01	01	H3370_024_0	10	4	Non-Preferred Brand	3	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00		2		
H3370	024	0	1	01	01	H3370_024_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H3370	024	0	1	01	01	H3370_024_0	10	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00					1		
H3370	024	0	1	01	01	H3370_024_0	10	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								87.50																		35.00								35.00		2		
H3370	025	0	1	01	01	H3370_025_0	12	4	Non-Preferred Brand	3	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00		2		
H3370	025	0	1	01	01	H3370_025_0	12	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								87.50																		35.00								35.00		2		
H3370	025	0	1	01	01	H3370_025_0	12	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00					1		
H3370	025	0	1	01	01	H3370_025_0	12	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H3370	025	0	1	01	01	H3370_025_0	12	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00				
H3370	025	0	1	01	01	H3370_025_0	12	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H3370	025	0	1	01	01	H3370_025_0	12	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H3370	025	0	1	01	01	H3370_025_0	12	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								87.50																		35.00								35.00				
H3370	025	0	1	01	01	H3370_025_0	12	6	Select Care Drugs	3	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00		1		
H3370	025	0	1	01	01	H3370_025_0	12	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H3370	025	0	1	01	01	H3370_025_0	12	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H3370	026	0	1	01	01	H3370_026_0	14	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00				
H3370	026	0	1	01	01	H3370_026_0	14	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H3370	026	0	1	01	01	H3370_026_0	14	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00					1		
H3370	026	0	1	01	01	H3370_026_0	14	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								87.50																		35.00								35.00		2		
H3370	026	0	1	01	01	H3370_026_0	14	4	Non-Preferred Brand	3	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00		2		
H3370	026	0	1	01	01	H3370_026_0	14	6	Select Care Drugs	3	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00		1		
H3370	026	0	1	01	01	H3370_026_0	14	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H3370	026	0	1	01	01	H3370_026_0	14	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H3370	026	0	1	01	01	H3370_026_0	14	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								87.50																		35.00								35.00				
H3370	026	0	1	01	01	H3370_026_0	14	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H3370	026	0	1	01	01	H3370_026_0	14	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H3370	027	0	1	01	01	H3370_027_0	9	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				5.00	10.00	15.00																						5.00	10.00	7.50																		5.00					5.00							
H3370	027	0	1	01	01	H3370_027_0	9	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				12.00	24.00	36.00																						12.00	24.00	18.00																		12.00					12.00							
H3370	027	0	1	01	01	H3370_027_0	9	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		44.00	88.00	132.00																						44.00	88.00	110.00																		44.00					44.00			44.00				
H3370	027	0	1	01	01	H3370_027_0	9	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		85.00	170.00	255.00																						85.00	170.00	212.50																		85.00					85.00			85.00				
H3370	027	0	1	01	01	H3370_027_0	9	5	Injectable Drugs	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					88.00	33	33	33																					33	33	33																	33				33			33			
H3370	027	0	1	01	01	H3370_027_0	9	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					909.00	33																							33																			33				33			33			
H3379	001	0	1	01	01	H3379_001_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00							
H3379	001	0	1	01	01	H3379_001_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					8.00		24.00																															16.00							24.00				8.00					8.00							
H3379	001	0	1	01	01	H3379_001_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H3379	001	0	1	01	01	H3379_001_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H3379	001	0	1	01	01	H3379_001_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					521.00	33		33																														33							33			33				33			33			
H3384	013	0	1	01	01	H3384_013_0	12	5	Specialty Tier	1	4	010010	1	1	110100000001101000000111	30		90							2	30		90								14	31	14	31	14					833.14	33		33																					33		28																		33			33			33			
H3384	013	0	1	01	01	H3384_013_0	12	1	Preferred Generic	1	4	001000	1	2	010100000001101000000110	30		90							2	30		90								14	31	14				0.00		0.00																						0.00		0.00																			0.00				0.00							
H3384	013	0	1	01	01	H3384_013_0	12	2	Non-Preferred Generic	1	4	000100	1	2	010100000001101000000110	30		90							2	30		90								14	31	14				8.00		24.00																						8.00		20.00																			8.00				8.00							
H3384	013	0	1	01	01	H3384_013_0	12	3	Preferred Brand	1	4	000001	1	2	110100000001101000000001	30		90							2	30		90								14			31	14		40.00		120.00																						40.00		100.00																			40.00							40.00				
H3384	013	0	1	01	01	H3384_013_0	12	4	Non-Preferred Brand	1	4	100000	1	1	110100000001101000000001	30		90							2	30		90								14			31	14					54.47	50		50																					50		42																		50						50			
H3384	019	0	1	01	01	H3384_019_0	11	3	Preferred Brand	1	4	000001	1	2	110100000001101000000001	30		90							2	30		90								14			31	14		45.00		135.00																						45.00		112.50																			45.00							45.00				
H3384	019	0	1	01	01	H3384_019_0	11	5	Specialty Tier	1	4	010010	1	1	110100000001101000000111	30		90							2	30		90								14	31	14	31	14					726.53	30		30																					30		25																		30			30			30			
H3384	019	0	1	01	01	H3384_019_0	11	4	Non-Preferred Brand	1	4	100000	1	1	110100000001101000000001	30		90							2	30		90								14			31	14					60.05	50		50																					50		42																		50						50			
H3384	019	0	1	01	01	H3384_019_0	11	2	Non-Preferred Generic	1	4	000100	1	2	010100000001101000000110	30		90							2	30		90								14	31	14				9.00		27.00																						9.00		22.50																			9.00				9.00							
H3384	019	0	1	01	01	H3384_019_0	11	1	Preferred Generic	1	4	001000	1	2	010100000001101000000110	30		90							2	30		90								14	31	14				0.00		0.00																						0.00		0.00																			0.00				0.00							
H3384	041	0	1	01	01	H3384_041_0	12	5	Specialty Tier	1	4	010010	1	1	110100000001101000000111	30		90							2	30		90								14	31	14	31	14					914.78	30		30																					30		25																		30			30			30			
H3384	041	0	1	01	01	H3384_041_0	12	1	Preferred Generic	1	4	001000	1	2	010100000001101000000110	30		90							2	30		90								14	31	14				0.00		0.00																						0.00		0.00																			0.00				0.00							
H3384	041	0	1	01	01	H3384_041_0	12	2	Non-Preferred Generic	1	4	000100	1	2	010100000001101000000110	30		90							2	30		90								14	31	14				5.00		15.00																						5.00		12.50																			5.00				5.00							
H3384	041	0	1	01	01	H3384_041_0	12	4	Non-Preferred Brand	1	4	100000	1	1	110100000001101000000001	30		90							2	30		90								14			31	14					58.99	50		50																					50		42																		50						50			
H3384	041	0	1	01	01	H3384_041_0	12	3	Preferred Brand	1	4	000001	1	2	110100000001101000000001	30		90							2	30		90								14			31	14		45.00		135.00																						45.00		112.50																			45.00							45.00				
H3384	053	0	1	01	01	H3384_053_0	10	4	Non-Preferred Brand	1	4	100000	1	1	110100000001101000000001	30		90							2	30		90								14			31	14					75.68	50		50																					50		42																		50						50			
H3384	053	0	1	01	01	H3384_053_0	10	5	Specialty Tier	1	4	010010	1	1	110100000001101000000111	30		90							2	30		90								14	31	14	31	14					1139.34	33		33																					33		28																		33			33			33			
H3384	053	0	1	01	01	H3384_053_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000001101000000110	30		90							2	30		90								14	31	14				9.00		27.00																						9.00		22.50																			9.00				9.00							
H3384	053	0	1	01	01	H3384_053_0	10	1	Preferred Generic	1	4	001000	1	2	010100000001101000000110	30		90							2	30		90								14	31	14				0.00		0.00																						0.00		0.00																			0.00				0.00							
H3384	053	0	1	01	01	H3384_053_0	10	3	Preferred Brand	1	4	000001	1	2	110100000001101000000001	30		90							2	30		90								14			31	14		40.00		120.00																						40.00		100.00																			40.00							40.00				
H3384	056	0	1	01	01	H3384_056_0	10	1	Preferred Generic	1	4	001000	1	2	010100000001101000000110	30		90							2	30		90								14	31	14				0.00		0.00																						0.00		0.00																			0.00				0.00							
H3384	056	0	1	01	01	H3384_056_0	10	3	Preferred Brand	3	4	000001	1	2	110100000001101000000001	30		90							2	30		90								14			31	14		45.00		135.00																						45.00		112.50																			45.00							45.00		2		
H3384	056	0	1	01	01	H3384_056_0	10	2	Non-Preferred Generic	3	4	000100	1	2	010100000001101000000110	30		90							2	30		90								14	31	14				4.00		12.00																						4.00		10.00																			4.00				4.00					2		
H3384	056	0	1	01	01	H3384_056_0	10	1	Preferred Generic	3	4	001000	1	2	010100000001101000000110	30		90							2	30		90								14	31	14				0.00		0.00																						0.00		0.00																			0.00				0.00					1		
H3384	056	0	1	01	01	H3384_056_0	10	5	Specialty Tier	1	4	010010	1	1	110100000001101000000111	30		90							2	30		90								14	31	14	31	14					965.97	30		30																					30		25																		30			30			30			
H3384	056	0	1	01	01	H3384_056_0	10	4	Non-Preferred Brand	1	4	100000	1	2	110100000001101000000001	30		90							2	30		90								14			31	14		75.00		225.00																						75.00		187.50																			75.00							75.00				
H3384	056	0	1	01	01	H3384_056_0	10	3	Preferred Brand	1	4	000001	1	2	110100000001101000000001	30		90							2	30		90								14			31	14		45.00		135.00																						45.00		112.50																			45.00							45.00				
H3384	056	0	1	01	01	H3384_056_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000001101000000110	30		90							2	30		90								14	31	14				4.00		12.00																						4.00		10.00																			4.00				4.00							
H3384	057	0	1	01	01	H3384_057_0	11	2	Non-Preferred Generic	1	4	000100	1	2	010100000001101000000110	30		90							2	30		90								14	31	14				7.00		21.00																						7.00		17.50																			7.00				7.00							
H3384	057	0	1	01	01	H3384_057_0	11	1	Preferred Generic	1	4	001000	1	2	010100000001101000000110	30		90							2	30		90								14	31	14				0.00		0.00																						0.00		0.00																			0.00				0.00							
H3384	057	0	1	01	01	H3384_057_0	11	4	Non-Preferred Brand	1	4	100000	1	1	110100000001101000000001	30		90							2	30		90								14			31	14					59.22	50		50																					50		42																		50						50			
H3384	057	0	1	01	01	H3384_057_0	11	5	Specialty Tier	1	4	010010	1	1	110100000001101000000111	30		90							2	30		90								14	31	14	31	14					858.94	33		33																					33		28																		33			33			33			
H3384	057	0	1	01	01	H3384_057_0	11	3	Preferred Brand	1	4	000001	1	2	110100000001101000000001	30		90							2	30		90								14			31	14		40.00		120.00																						40.00		100.00																			40.00							40.00				
H3388	002	0	1	01	01	H3388_002_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							1	30		90							30		31					8.00		24.00																						8.00		16.00																		8.00					8.00							
H3388	002	0	1	01	01	H3388_002_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							1	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00							
H3388	002	0	1	01	01	H3388_002_0	10	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		90							1	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00					1		
H3388	002	0	1	01	01	H3388_002_0	10	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					628.24	30																							30																			30				30			30			
H3388	002	0	1	01	01	H3388_002_0	10	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000100	30		90							1	30		90							30		31					8.00		24.00																						8.00		16.00																		8.00					8.00					1		
H3388	002	0	1	01	01	H3388_002_0	10	3	Preferred Brand	1	4	010001	1	2	110100000010101000000101	30		90							1	30		90							30		31		31	14		40.00		120.00																						40.00		80.00																		40.00					40.00			40.00				
H3388	002	0	1	01	01	H3388_002_0	10	4	Non-Preferred Brand	1	4	110000	1	2	110100000010101000000101	30		90							1	30		90							30		31		31	14		90.00		270.00																						90.00		225.00																		90.00					90.00			90.00				
H3388	004	0	1	01	01	H3388_004_0	11	4	Non-Preferred Brand	1	4	110000	1	2	110100000010101000000101	30		90							1	30		90							30		31		31	14		95.00		285.00																						95.00		237.50																		95.00					95.00			95.00				
H3388	004	0	1	01	01	H3388_004_0	11	3	Preferred Brand	1	4	010001	1	2	110100000010101000000101	30		90							1	30		90							30		31		31	14		45.00		135.00																						45.00		90.00																		45.00					45.00			45.00				
H3388	004	0	1	01	01	H3388_004_0	11	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					811.24	33																							33																			33				33			33			
H3388	004	0	1	01	01	H3388_004_0	11	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							1	30		90							30		31					9.00		27.00																						9.00		18.00																		9.00					9.00							
H3388	004	0	1	01	01	H3388_004_0	11	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							1	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00							
H3404	001	0	1	04	01	H3404_001_0	8	1	Preferred Generic	1	4	001000	1	2	011100000010000111111110	30	60	90							2				30	60	90	30	60	90	30		31	14				8.00	16.00	24.00																													0.00	0.00	0.00					8.00	16.00	24.00				8.00					8.00							
H3404	001	0	1	04	01	H3404_001_0	8	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111110	30	60	90							2				30	60	90	30	60	90	30		31	14				25.00	50.00	75.00																													25.00	50.00	62.50					25.00	50.00	75.00				25.00					25.00							
H3404	001	0	1	04	01	H3404_001_0	8	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		40.00	80.00	120.00																													40.00	80.00	100.00					40.00	80.00	120.00				40.00								40.00				
H3404	001	0	1	04	01	H3404_001_0	8	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		80.00	160.00	240.00																													80.00	160.00	200.00					80.00	160.00	240.00				80.00								80.00				
H3404	001	0	1	04	01	H3404_001_0	8	5	Specialty Tier	1	4	101101	1	1	111100000010000111111111	30	60	90							2				30	60	90	30	60	90	30		31	14	31	14					33.00	33	33	33																												33	33	33					33	33	33			33				33			33			
H3404	002	0	1	04	01	H3404_002_0	9	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111110	30	60	90							2				30	60	90	30	60	90	30		31	14				20.00	40.00	60.00																													20.00	40.00	50.00					20.00	40.00	60.00				20.00					20.00							
H3404	002	0	1	04	01	H3404_002_0	9	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		30.00	60.00	90.00																													30.00	60.00	75.00					30.00	60.00	90.00				30.00								30.00				
H3404	002	0	1	04	01	H3404_002_0	9	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		70.00	140.00	210.00																													70.00	140.00	175.00					70.00	140.00	210.00				70.00								70.00				
H3404	002	0	1	04	01	H3404_002_0	9	5	Specialty Tier	1	4	101101	1	1	111100000010000111111111	30	60	90							2				30	60	90	30	60	90	30		31	14	31	14					33.00	33	33	33																												33	33	33					33	33	33			33				33			33			
H3404	002	0	1	04	01	H3404_002_0	9	1	Preferred Generic	1	4	001000	1	2	011100000010000111111110	30	60	90							2				30	60	90	30	60	90	30		31	14				4.00	8.00	12.00																													0.00	0.00	0.00					4.00	8.00	12.00				4.00					4.00							
H3404	002	0	1	04	01	H3404_002_0	9	1	Preferred Generic	3	4	001000	1	2	011100000010000111111110	30	60	90							2				30	60	90	30	60	90	30		31	14				4.00	8.00	12.00																													0.00	0.00	0.00					4.00	8.00	12.00				4.00					4.00					1		
H3405	001	0	1	04	01	H3405_001_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H3405	001	0	1	04	01	H3405_001_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					800.00	33																														33							33					33				33			33	2	3	
H3405	001	0	1	04	01	H3405_001_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H3405	001	0	1	04	01	H3405_001_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H3405	001	0	1	04	01	H3405_001_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00		2	3	
H3405	001	0	1	04	01	H3405_001_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					654.00	33																														33							33					33				33			33			
H3405	001	0	1	04	01	H3405_001_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H3405	001	0	1	04	01	H3405_001_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H3405	001	0	1	04	01	H3405_001_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H3405	001	0	1	04	01	H3405_001_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00				
H3405	002	0	1	04	01	H3405_002_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00				
H3405	002	0	1	04	01	H3405_002_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					940.00	33																														33							33					33				33			33	2	3	
H3405	002	0	1	04	01	H3405_002_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H3405	002	0	1	04	01	H3405_002_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H3405	002	0	1	04	01	H3405_002_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H3405	002	0	1	04	01	H3405_002_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H3405	002	0	1	04	01	H3405_002_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H3405	002	0	1	04	01	H3405_002_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					853.00	33																														33							33					33				33			33			
H3405	002	0	1	04	01	H3405_002_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00		2	3	
H3405	002	0	1	04	01	H3405_002_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H3405	005	0	1	04	01	H3405_005_0	8	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00		2	3	
H3405	005	0	1	04	01	H3405_005_0	8	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H3405	005	0	1	04	01	H3405_005_0	8	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H3405	005	0	1	04	01	H3405_005_0	8	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1031.00	33																														33							33					33				33			33	2	3	
H3405	005	0	1	04	01	H3405_005_0	8	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H3405	005	0	1	04	01	H3405_005_0	8	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00				
H3405	005	0	1	04	01	H3405_005_0	8	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H3405	005	0	1	04	01	H3405_005_0	8	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H3405	005	0	1	04	01	H3405_005_0	8	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H3405	005	0	1	04	01	H3405_005_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					916.00	33																														33							33					33				33			33			
H3405	007	0	1	04	01	H3405_007_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H3405	007	0	1	04	01	H3405_007_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H3405	007	0	1	04	01	H3405_007_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H3405	007	0	1	04	01	H3405_007_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00		2	3	
H3405	007	0	1	04	01	H3405_007_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1217.00	33																														33							33					33				33			33	2	3	
H3405	007	0	1	04	01	H3405_007_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H3405	007	0	1	04	01	H3405_007_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H3405	007	0	1	04	01	H3405_007_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H3405	007	0	1	04	01	H3405_007_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1119.00	33																														33							33					33				33			33			
H3405	007	0	1	04	01	H3405_007_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00				
H3421	002	0	1	09	04	H3421_002_0	9	1	Preferred Generic	1	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		4.00		12.00																						4.00		10.00																		4.00					4.00			4.00				
H3421	002	0	1	09	04	H3421_002_0	9	4	Specialty Tier	1	4	100100	1	1	110100000010101000000111	30		90							1	30		90							30		31	14	31	14					694.00	33		33																					33		33																	33				33			33			
H3421	002	0	1	09	04	H3421_002_0	9	3	Non-Preferred Brand	1	4	100100	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		78.00		234.00																						78.00		195.00																		78.00					78.00			78.00				
H3421	002	0	1	09	04	H3421_002_0	9	2	Preferred Brand	1	4	000101	1	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		44.00		132.00																						44.00		110.00																		44.00					44.00			44.00				
H3447	001	0	1	01	01	H3447_001_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H3447	001	0	1	01	01	H3447_001_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H3447	001	0	1	01	01	H3447_001_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								87.50																		35.00								35.00				
H3447	001	0	1	01	01	H3447_001_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H3447	001	0	1	01	01	H3447_001_0	9	4	Non-Preferred Brand	3	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00		2		
H3447	001	0	1	01	01	H3447_001_0	9	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		10.00		30.00																								25.00																		10.00								10.00				
H3447	001	0	1	01	01	H3447_001_0	9	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H3447	001	0	1	01	01	H3447_001_0	9	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00					1		
H3447	001	0	1	01	01	H3447_001_0	9	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								87.50																		35.00								35.00		2		
H3447	001	0	1	01	01	H3447_001_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H3447	002	0	1	01	01	H3447_002_0	10	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H3447	002	0	1	01	01	H3447_002_0	10	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H3447	002	0	1	01	01	H3447_002_0	10	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								87.50																		35.00								35.00				
H3447	002	0	1	01	01	H3447_002_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H3447	002	0	1	01	01	H3447_002_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H3447	002	0	1	01	01	H3447_002_0	10	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00				
H3447	002	0	1	01	01	H3447_002_0	10	6	Select Care Drugs	3	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00		1		
H3447	002	0	1	01	01	H3447_002_0	10	4	Non-Preferred Brand	3	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00		2		
H3447	002	0	1	01	01	H3447_002_0	10	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								87.50																		35.00								35.00		2		
H3447	002	0	1	01	01	H3447_002_0	10	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00					1		
H3447	002	0	1	01	01	H3447_002_0	10	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H3447	003	0	1	01	01	H3447_003_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H3447	003	0	1	01	01	H3447_003_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H3447	003	0	1	01	01	H3447_003_0	10	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								87.50																		35.00								35.00				
H3447	003	0	1	01	01	H3447_003_0	10	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H3447	003	0	1	01	01	H3447_003_0	10	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H3447	003	0	1	01	01	H3447_003_0	10	6	Select Care Drugs	3	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00		1		
H3447	003	0	1	01	01	H3447_003_0	10	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								87.50																		35.00								35.00		2		
H3447	003	0	1	01	01	H3447_003_0	10	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00					1		
H3447	003	0	1	01	01	H3447_003_0	10	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H3447	003	0	1	01	01	H3447_003_0	10	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00				
H3447	003	0	1	01	01	H3447_003_0	10	4	Non-Preferred Brand	3	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00		2		
H3447	004	0	1	01	01	H3447_004_0	12	4	Non-Preferred Brand	3	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00		2		
H3447	004	0	1	01	01	H3447_004_0	12	6	Select Care Drugs	3	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00		1		
H3447	004	0	1	01	01	H3447_004_0	12	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H3447	004	0	1	01	01	H3447_004_0	12	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H3447	004	0	1	01	01	H3447_004_0	12	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								87.50																		35.00								35.00				
H3447	004	0	1	01	01	H3447_004_0	12	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H3447	004	0	1	01	01	H3447_004_0	12	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H3447	004	0	1	01	01	H3447_004_0	12	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00				
H3447	004	0	1	01	01	H3447_004_0	12	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H3447	004	0	1	01	01	H3447_004_0	12	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00					1		
H3447	004	0	1	01	01	H3447_004_0	12	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								87.50																		35.00								35.00		2		
H3449	005	0	1	01	01	H3449_005_0	8	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111110	30	60	90							2				30	60	90	30	60	90	30		31	14				20.00	40.00	60.00																													20.00	40.00	50.00					20.00	40.00	60.00				20.00					20.00							
H3449	005	0	1	01	01	H3449_005_0	8	1	Preferred Generic	1	4	001000	1	2	011100000010000111111110	30	60	90							2				30	60	90	30	60	90	30		31	14				4.00	8.00	12.00																													0.00	0.00	0.00					4.00	8.00	12.00				4.00					4.00							
H3449	005	0	1	01	01	H3449_005_0	8	1	Preferred Generic	3	4	001000	1	2	011100000010000111111110	30	60	90							2				30	60	90	30	60	90	30		31	14				4.00	8.00	12.00																													0.00	0.00	0.00					4.00	8.00	12.00				4.00					4.00					1		
H3449	005	0	1	01	01	H3449_005_0	8	5	Specialty Tier	1	4	101101	1	1	111100000010000111111111	30	60	90							2				30	60	90	30	60	90	30		31	14	31	14					33.00	33	33	33																												33	33	33					33	33	33			33				33			33			
H3449	005	0	1	01	01	H3449_005_0	8	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		70.00	140.00	210.00																													70.00	140.00	175.00					70.00	140.00	210.00				70.00								70.00				
H3449	005	0	1	01	01	H3449_005_0	8	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		30.00	60.00	90.00																													30.00	60.00	75.00					30.00	60.00	90.00				30.00								30.00				
H3449	013	0	1	01	01	H3449_013_0	6	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		40.00	80.00	120.00																													40.00	80.00	100.00					40.00	80.00	120.00				40.00								40.00				
H3449	013	0	1	01	01	H3449_013_0	6	5	Specialty Tier	1	4	101101	1	1	111100000010000111111111	30	60	90							2				30	60	90	30	60	90	30		31	14	31	14					33.00	33	33	33																												33	33	33					33	33	33			33				33			33			
H3449	013	0	1	01	01	H3449_013_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		80.00	160.00	240.00																													80.00	160.00	200.00					80.00	160.00	240.00				80.00								80.00				
H3449	013	0	1	01	01	H3449_013_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111110	30	60	90							2				30	60	90	30	60	90	30		31	14				25.00	50.00	75.00																													25.00	50.00	62.50					25.00	50.00	75.00				25.00					25.00							
H3449	013	0	1	01	01	H3449_013_0	6	1	Preferred Generic	1	4	001000	1	2	011100000010000111111110	30	60	90							2				30	60	90	30	60	90	30		31	14				7.00	14.00	21.00																													0.00	0.00	0.00					7.00	14.00	21.00				7.00					7.00							
H3456	001	0	1	01	01	H3456_001_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H3456	001	0	1	01	01	H3456_001_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H3456	001	0	1	01	01	H3456_001_0	8	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H3456	001	0	1	01	01	H3456_001_0	8	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					492.00	33		33																														33							33			33				33			33			
H3456	001	0	1	01	01	H3456_001_0	8	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H3456	023	0	1	02	01	H3456_023_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H3456	023	0	1	02	01	H3456_023_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H3456	023	0	1	02	01	H3456_023_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H3456	023	0	1	02	01	H3456_023_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H3456	023	0	1	02	01	H3456_023_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					492.00	33		33																														33							33			33				33			33			
H3456	025	0	1	02	01	H3456_025_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H3456	025	0	1	02	01	H3456_025_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H3456	025	0	1	02	01	H3456_025_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					479.00	33		33																														33							33			33				33			33			
H3456	025	0	1	02	01	H3456_025_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H3456	025	0	1	02	01	H3456_025_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H3511	001	0	1	04	01	H3511_001_0	9	5	Specialty Tier	1	4	000010	1	1	110100000001001000000001	30		90							1			90								29			31	2					33.00	33		33																							33																		33						33			
H3511	001	0	1	04	01	H3511_001_0	9	1	Preferred Generic	1	4	001000	1	2	010100000001001000000100	30		90							1			90								29	31					4.00		12.00																								12.00																			4.00				4.00							
H3511	001	0	1	04	01	H3511_001_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000001001000000100	30		90							1			90								29	31					4.00		12.00																								12.00																			4.00				4.00							
H3511	001	0	1	04	01	H3511_001_0	9	3	Preferred Brand	1	4	000001	1	2	110100000001001000000001	30		90							1			90								29			31	2		36.00		108.00																								108.00																			36.00							36.00				
H3511	001	0	1	04	01	H3511_001_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000001001000000001	30		90							1			90								29			31	2		75.00		225.00																								225.00																			75.00							75.00				
H3511	002	0	1	04	01	H3511_002_0	9	1	Preferred Generic	1	4	001000	1	2	010100000001001000000100	30		90							1			90								29	31					0.00		0.00																								0.00																			0.00				0.00							
H3511	002	0	1	04	01	H3511_002_0	9	3	Preferred Brand	1	4	000001	1	2	110100000001001000000001	30		90							1			90								29			31	2		36.00		108.00																								108.00																			36.00							36.00				
H3511	002	0	1	04	01	H3511_002_0	9	5	Specialty Tier	1	4	000010	1	1	110100000001001000000001	30		90							1			90								29			31	2					33.00	33		33																							33																		33						33			
H3511	002	0	1	04	01	H3511_002_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000001001000000001	30		90							1			90								29			31	2		75.00		225.00																								225.00																			75.00							75.00				
H3511	002	0	1	04	01	H3511_002_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000001001000000100	30		90							1			90								29	31					0.00		0.00																								0.00																			0.00				0.00							
H3528	001	0	1	01	01	H3528_001_0	14	1	Preferred Generic	1	4	001000	1	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					10.00	20.00	30.00																						10.00	20.00	20.00																		10.00					10.00							
H3528	001	0	1	01	01	H3528_001_0	14	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							2	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.00																		45.00								45.00				
H3528	001	0	1	01	01	H3528_001_0	14	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							2	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.00																		95.00								95.00				
H3528	001	0	1	01	01	H3528_001_0	14	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					1237.48	33	33	33																					33	33	33																	33				33			33			
H3528	002	0	1	01	01	H3528_002_0	9	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					1633.47	33	33	33																					33	33	33																	33				33			33			
H3528	002	0	1	01	01	H3528_002_0	9	1	Preferred Generic	3	4	001000	1	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					10.00	20.00	30.00																						10.00	20.00	20.00																		10.00					10.00					1		
H3528	002	0	1	01	01	H3528_002_0	9	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							2	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.00																		95.00								95.00				
H3528	002	0	1	01	01	H3528_002_0	9	1	Preferred Generic	1	4	001000	1	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					10.00	20.00	30.00																						10.00	20.00	20.00																		10.00					10.00							
H3528	002	0	1	01	01	H3528_002_0	9	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							2	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.00																		45.00								45.00				
H3528	006	0	1	02	01	H3528_006_0	11	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							2	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.00																		45.00								45.00				
H3528	006	0	1	02	01	H3528_006_0	11	1	Preferred Generic	3	4	001000	1	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					10.00	20.00	30.00																						10.00	20.00	20.00																		10.00					10.00					1		
H3528	006	0	1	02	01	H3528_006_0	11	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					1633.47	33	33	33																					33	33	33																	33				33			33			
H3528	006	0	1	02	01	H3528_006_0	11	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							2	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.00																		95.00								95.00				
H3528	006	0	1	02	01	H3528_006_0	11	1	Preferred Generic	1	4	001000	1	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					10.00	20.00	30.00																						10.00	20.00	20.00																		10.00					10.00							
H3528	008	0	1	02	01	H3528_008_0	10	1	Preferred Generic	1	4	001000	1	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					10.00	20.00	30.00																						10.00	20.00	20.00																		10.00					10.00							
H3528	008	0	1	02	01	H3528_008_0	10	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					1237.48	33	33	33																					33	33	33																	33				33			33			
H3528	008	0	1	02	01	H3528_008_0	10	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							2	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.00																		95.00								95.00				
H3528	008	0	1	02	01	H3528_008_0	10	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							2	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.00																		45.00								45.00				
H3528	009	0	1	01	01	H3528_009_0	10	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					1237.48	33	33	33																					33	33	33																	33				33			33			
H3528	009	0	1	01	01	H3528_009_0	10	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							2	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.00																		95.00								95.00				
H3528	009	0	1	01	01	H3528_009_0	10	1	Preferred Generic	1	4	001000	1	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					10.00	20.00	30.00																						10.00	20.00	20.00																		10.00					10.00							
H3528	009	0	1	01	01	H3528_009_0	10	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							2	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.00																		45.00								45.00				
H3533	001	0	1	01	01	H3533_001_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H3533	001	0	1	01	01	H3533_001_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H3533	001	0	1	01	01	H3533_001_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H3533	001	0	1	01	01	H3533_001_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H3533	001	0	1	01	01	H3533_001_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					3443.00	33																														33							33					33				33			33	2	3	
H3533	001	0	1	01	01	H3533_001_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H3533	001	0	1	01	01	H3533_001_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H3533	001	0	1	01	01	H3533_001_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H3533	001	0	1	01	01	H3533_001_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H3533	001	0	1	01	01	H3533_001_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1060.00	33																														33							33					33				33			33			
H3533	002	0	1	01	01	H3533_002_0	8	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H3533	002	0	1	01	01	H3533_002_0	8	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					271.00	25																														25							25					25				25			25			
H3533	002	0	1	01	01	H3533_002_0	8	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H3533	002	0	1	01	01	H3533_002_0	8	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H3597	001	0	1	01	01	H3597_001_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H3597	001	0	1	01	01	H3597_001_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H3597	001	0	1	01	01	H3597_001_0	6	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H3597	001	0	1	01	01	H3597_001_0	6	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					191.70	33	33	33																												33	33	33					33	33	33				33			33			33			
H3597	001	0	1	01	01	H3597_001_0	6	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					6.00	12.00	18.00																													6.00	12.00	12.00					6.00	12.00	18.00					6.00				6.00							
H3597	002	0	1	01	01	H3597_002_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H3597	002	0	1	01	01	H3597_002_0	6	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H3597	002	0	1	01	01	H3597_002_0	6	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					184.99	33	33	33																												33	33	33					33	33	33				33			33			33			
H3597	002	0	1	01	01	H3597_002_0	6	1	Preferred Generic	3	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					6.00	12.00	18.00																													6.00	12.00	12.00					6.00	12.00	18.00					6.00				6.00					1		
H3597	002	0	1	01	01	H3597_002_0	6	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					6.00	12.00	18.00																													6.00	12.00	12.00					6.00	12.00	18.00					6.00				6.00							
H3597	002	0	1	01	01	H3597_002_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H3619	001	0	1	04	01	H3619_001_0	4	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H3619	001	0	1	04	01	H3619_001_0	4	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H3619	001	0	1	04	01	H3619_001_0	4	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H3619	001	0	1	04	01	H3619_001_0	4	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H3619	001	0	1	04	01	H3619_001_0	4	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					895.00	33																														33							33					33				33			33	2	3	
H3619	001	0	1	04	01	H3619_001_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H3619	001	0	1	04	01	H3619_001_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H3619	001	0	1	04	01	H3619_001_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H3619	001	0	1	04	01	H3619_001_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H3619	001	0	1	04	01	H3619_001_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					806.00	33																														33							33					33				33			33			
H3619	004	0	1	04	01	H3619_004_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					709.00	33																														33							33					33				33			33	2	3	
H3619	004	0	1	04	01	H3619_004_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H3619	004	0	1	04	01	H3619_004_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H3619	004	0	1	04	01	H3619_004_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H3619	004	0	1	04	01	H3619_004_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H3619	004	0	1	04	01	H3619_004_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					643.00	33																														33							33					33				33			33			
H3619	004	0	1	04	01	H3619_004_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H3619	004	0	1	04	01	H3619_004_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H3619	004	0	1	04	01	H3619_004_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H3619	004	0	1	04	01	H3619_004_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H3619	012	0	1	04	01	H3619_012_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					562.00	33																														33							33					33				33			33			
H3619	012	0	1	04	01	H3619_012_0	4	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H3619	012	0	1	04	01	H3619_012_0	4	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H3619	012	0	1	04	01	H3619_012_0	4	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H3619	012	0	1	04	01	H3619_012_0	4	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					595.00	33																														33							33					33				33			33	2	3	
H3619	012	0	1	04	01	H3619_012_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H3619	012	0	1	04	01	H3619_012_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H3619	012	0	1	04	01	H3619_012_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H3619	012	0	1	04	01	H3619_012_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H3619	012	0	1	04	01	H3619_012_0	4	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H3619	013	0	1	04	01	H3619_013_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					890.00	33																														33							33					33				33			33			
H3619	013	0	1	04	01	H3619_013_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H3619	013	0	1	04	01	H3619_013_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H3619	013	0	1	04	01	H3619_013_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H3619	013	0	1	04	01	H3619_013_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H3619	013	0	1	04	01	H3619_013_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H3619	013	0	1	04	01	H3619_013_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H3619	013	0	1	04	01	H3619_013_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H3619	013	0	1	04	01	H3619_013_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H3619	013	0	1	04	01	H3619_013_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1084.00	33																														33							33					33				33			33	2	3	
H3619	014	0	1	04	01	H3619_014_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					897.00	33																														33							33					33				33			33			
H3619	014	0	1	04	01	H3619_014_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H3619	014	0	1	04	01	H3619_014_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H3619	014	0	1	04	01	H3619_014_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H3619	014	0	1	04	01	H3619_014_0	4	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1057.00	33																														33							33					33				33			33	2	3	
H3619	014	0	1	04	01	H3619_014_0	4	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H3619	014	0	1	04	01	H3619_014_0	4	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H3619	014	0	1	04	01	H3619_014_0	4	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H3619	014	0	1	04	01	H3619_014_0	4	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H3619	014	0	1	04	01	H3619_014_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H3619	015	0	1	04	01	H3619_015_0	4	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1003.00	33																														33							33					33				33			33	2	3	
H3619	015	0	1	04	01	H3619_015_0	4	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H3619	015	0	1	04	01	H3619_015_0	4	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H3619	015	0	1	04	01	H3619_015_0	4	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H3619	015	0	1	04	01	H3619_015_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					863.00	33																														33							33					33				33			33			
H3619	015	0	1	04	01	H3619_015_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H3619	015	0	1	04	01	H3619_015_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H3619	015	0	1	04	01	H3619_015_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H3619	015	0	1	04	01	H3619_015_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H3619	015	0	1	04	01	H3619_015_0	4	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H3619	016	0	1	04	01	H3619_016_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					829.00	33																														33							33					33				33			33			
H3619	016	0	1	04	01	H3619_016_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H3619	016	0	1	04	01	H3619_016_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H3619	016	0	1	04	01	H3619_016_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H3619	016	0	1	04	01	H3619_016_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H3619	016	0	1	04	01	H3619_016_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1005.00	33																														33							33					33				33			33	2	3	
H3619	016	0	1	04	01	H3619_016_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H3619	016	0	1	04	01	H3619_016_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H3619	016	0	1	04	01	H3619_016_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H3619	016	0	1	04	01	H3619_016_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H3619	019	0	1	04	01	H3619_019_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H3619	019	0	1	04	01	H3619_019_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					798.00	33																														33							33					33				33			33			
H3619	019	0	1	04	01	H3619_019_0	4	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H3619	019	0	1	04	01	H3619_019_0	4	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H3619	019	0	1	04	01	H3619_019_0	4	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H3619	019	0	1	04	01	H3619_019_0	4	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H3619	019	0	1	04	01	H3619_019_0	4	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					896.00	33																														33							33					33				33			33	2	3	
H3619	019	0	1	04	01	H3619_019_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H3619	019	0	1	04	01	H3619_019_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H3619	019	0	1	04	01	H3619_019_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H3619	020	0	1	04	01	H3619_020_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H3619	020	0	1	04	01	H3619_020_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H3619	020	0	1	04	01	H3619_020_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					962.00	33																														33							33					33				33			33	2	3	
H3619	020	0	1	04	01	H3619_020_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H3619	020	0	1	04	01	H3619_020_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H3619	020	0	1	04	01	H3619_020_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H3619	020	0	1	04	01	H3619_020_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H3619	020	0	1	04	01	H3619_020_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					862.00	33																														33							33					33				33			33			
H3619	020	0	1	04	01	H3619_020_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H3619	020	0	1	04	01	H3619_020_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H3619	021	0	1	04	01	H3619_021_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H3619	021	0	1	04	01	H3619_021_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H3619	021	0	1	04	01	H3619_021_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H3619	021	0	1	04	01	H3619_021_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H3619	021	0	1	04	01	H3619_021_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					898.00	33																														33							33					33				33			33	2	3	
H3619	021	0	1	04	01	H3619_021_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					799.00	33																														33							33					33				33			33			
H3619	021	0	1	04	01	H3619_021_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H3619	021	0	1	04	01	H3619_021_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H3619	021	0	1	04	01	H3619_021_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H3619	021	0	1	04	01	H3619_021_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H3620	004	0	1	04	01	H3620_004_0	8	2	Preferred Brand	1	3	000001		2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	135.00																		45.00								45.00				
H3620	004	0	1	04	01	H3620_004_0	8	4	Specialty Tier	1	3	000010		1	111100000010111000000001	30	60	90							1	30	60	90							30				31	14					1000.44	33	33	33																					33	33	33																	33							33			
H3620	004	0	1	04	01	H3620_004_0	8	3	Non-Preferred Brand	1	3	100000		2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	285.00																		95.00								95.00				
H3620	004	0	1	04	01	H3620_004_0	8	1	Generic	1	3	010000		2	011100000010111000000110	30	60	90							1	30	60	90							30		31	14				10.00	20.00	30.00																						10.00	20.00	30.00																		10.00					10.00							
H3623	001	0	1	01	01	H3623_001_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H3623	001	0	1	01	01	H3623_001_0	6	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					7.00	14.00	21.00																													7.00	14.00	14.00					7.00	14.00	21.00					7.00				7.00							
H3623	001	0	1	01	01	H3623_001_0	6	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H3623	001	0	1	01	01	H3623_001_0	6	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					199.99	33	33	33																												33	33	33					33	33	33				33			33			33			
H3623	001	0	1	01	01	H3623_001_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H3623	003	0	1	01	01	H3623_003_0	6	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					147.23	33	33	33																												33	33	33					33	33	33				33			33			33			
H3623	003	0	1	01	01	H3623_003_0	6	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H3623	003	0	1	01	01	H3623_003_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H3623	003	0	1	01	01	H3623_003_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H3623	003	0	1	01	01	H3623_003_0	6	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					0.00	0.00	0.00																													0.00	0.00	0.00					0.00	0.00	0.00					0.00				0.00							
H3623	004	0	1	01	01	H3623_004_0	7	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H3623	004	0	1	01	01	H3623_004_0	7	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					124.62	33	33	33																												33	33	33					33	33	33				33			33			33			
H3623	004	0	1	01	01	H3623_004_0	7	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H3623	004	0	1	01	01	H3623_004_0	7	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H3623	004	0	1	01	01	H3623_004_0	7	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					7.00	14.00	21.00																													7.00	14.00	14.00					7.00	14.00	21.00					7.00				7.00							
H3623	018	0	1	01	01	H3623_018_0	6	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					4.00	8.00	12.00																													4.00	8.00	8.00					4.00	8.00	12.00					4.00				4.00							
H3623	018	0	1	01	01	H3623_018_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H3623	018	0	1	01	01	H3623_018_0	6	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H3623	018	0	1	01	01	H3623_018_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H3623	018	0	1	01	01	H3623_018_0	6	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					312.10	33	33	33																												33	33	33					33	33	33				33			33			33			
H3653	004	0	1	01	01	H3653_004_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							2			90							30		31					8.00		24.00																								16.00																		8.00					8.00							
H3653	004	0	1	01	01	H3653_004_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		40.00		120.00																								80.00																		40.00								40.00				
H3653	004	0	1	01	01	H3653_004_0	6	4	Injectable Drugs	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					38.14	33																																										33				33			33			
H3653	004	0	1	01	01	H3653_004_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					706.70	33																																										33				33			33			
H3653	004	0	1	01	01	H3653_004_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							2			90							30		31					2.00		6.00																								4.00																		2.00					2.00							
H3653	015	0	1	01	01	H3653_015_0	7	4	Injectable Drugs	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					87.63	33																																										33				33			33			
H3653	015	0	1	01	01	H3653_015_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		45.00		135.00																								135.00																		45.00								45.00				
H3653	015	0	1	01	01	H3653_015_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							2			90							30		31					15.00		45.00																								45.00																		15.00					15.00							
H3653	015	0	1	01	01	H3653_015_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							2			90							30		31					5.00		15.00																								15.00																		5.00					5.00							
H3653	015	0	1	01	01	H3653_015_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					586.99	33																																										33				33			33			
H3655	013	0	1	01	01	H3655_013_0	12	5	Injectable Drugs	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					58.00	33	33	33																					33	33	33																	33				33			33			
H3655	013	0	1	01	01	H3655_013_0	12	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					925.00	33																							33																			33				33			33			
H3655	013	0	1	01	01	H3655_013_0	12	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H3655	013	0	1	01	01	H3655_013_0	12	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00					45.00			45.00				
H3655	013	0	1	01	01	H3655_013_0	12	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				11.00	22.00	33.00																						11.00	22.00	16.50																		11.00					11.00							
H3655	013	0	1	01	01	H3655_013_0	12	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				4.00	8.00	12.00																						4.00	8.00	6.00																		4.00					4.00							
H3655	030	0	1	01	01	H3655_030_0	11	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H3655	030	0	1	01	01	H3655_030_0	11	5	Injectable Drugs	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					79.00	33	33	33																					33	33	33																	33				33			33			
H3655	030	0	1	01	01	H3655_030_0	11	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00					45.00			45.00				
H3655	030	0	1	01	01	H3655_030_0	11	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	14.00	10.50																		7.00					7.00							
H3655	030	0	1	01	01	H3655_030_0	11	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				4.00	8.00	12.00																						4.00	8.00	6.00																		4.00					4.00							
H3655	030	0	1	01	01	H3655_030_0	11	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					1036.00	33																							33																			33				33			33			
H3659	001	0	1	02	01	H3659_001_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H3659	001	0	1	02	01	H3659_001_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H3659	001	0	1	02	01	H3659_001_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H3659	001	0	1	02	01	H3659_001_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H3659	001	0	1	02	01	H3659_001_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					473.00	33		33																														33							33			33				33			33			
H3659	003	0	1	01	01	H3659_003_0	7	1	Preferred Generic	3	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00					1		
H3659	003	0	1	01	01	H3659_003_0	7	2	Non-Preferred Generic	3	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00					1		
H3659	003	0	1	01	01	H3659_003_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00							
H3659	003	0	1	01	01	H3659_003_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H3659	003	0	1	01	01	H3659_003_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H3659	003	0	1	01	01	H3659_003_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H3659	003	0	1	01	01	H3659_003_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					557.00	33		33																														33							33			33				33			33			
H3659	031	0	1	01	01	H3659_031_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															0.00							9.00				3.00					3.00							
H3659	031	0	1	01	01	H3659_031_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															0.00							18.00				6.00					6.00							
H3659	031	0	1	01	01	H3659_031_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H3659	031	0	1	01	01	H3659_031_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H3659	031	0	1	01	01	H3659_031_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					547.00	33		33																														33							33			33				33			33			
H3660	028	0	1	02	01	H3660_028_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H3660	028	0	1	02	01	H3660_028_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				10.00		30.00																								25.00																		10.00					10.00							
H3660	028	0	1	02	01	H3660_028_0	8	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				10.00		30.00																								25.00																		10.00					10.00					1		
H3660	028	0	1	02	01	H3660_028_0	8	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H3660	028	0	1	02	01	H3660_028_0	8	5	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							1			90							30		31	14	31	14					618.08	33		33																							33																	33				33			33			
H3660	028	0	1	02	01	H3660_028_0	8	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		90.00		270.00																								270.00																		90.00								90.00				
H3660	028	0	1	02	01	H3660_028_0	8	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		45.00		135.00																								112.50																		45.00								45.00				
H3660	029	0	1	02	01	H3660_029_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		45.00		135.00																								112.50																		45.00								45.00				
H3660	029	0	1	02	01	H3660_029_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				10.00		30.00																								25.00																		10.00					10.00							
H3660	029	0	1	02	01	H3660_029_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H3660	029	0	1	02	01	H3660_029_0	7	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				10.00		30.00																								25.00																		10.00					10.00					1		
H3660	029	0	1	02	01	H3660_029_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		90.00		270.00																								270.00																		90.00								90.00				
H3660	029	0	1	02	01	H3660_029_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							1			90							30		31	14	31	14					820.45	33		33																							33																	33				33			33			
H3660	029	0	1	02	01	H3660_029_0	7	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H3660	044	0	1	01	01	H3660_044_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		45.00		135.00																								112.50																		45.00								45.00				
H3660	044	0	1	01	01	H3660_044_0	6	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				5.00		15.00																								12.50																		5.00					5.00					1		
H3660	044	0	1	01	01	H3660_044_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		90.00		270.00																								270.00																		90.00								90.00				
H3660	044	0	1	01	01	H3660_044_0	6	5	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							1			90							30		31	14	31	14					334.47	33		33																							33																	33				33			33			
H3660	044	0	1	01	01	H3660_044_0	6	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H3660	044	0	1	01	01	H3660_044_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				5.00		15.00																								12.50																		5.00					5.00							
H3660	044	0	1	01	01	H3660_044_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H3664	017	0	1	02	01	H3664_017_0	6	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		80.00	160.00	240.00																						80.00	160.00	240.00																		80.00								80.00				
H3664	017	0	1	02	01	H3664_017_0	6	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	135.00																		45.00								45.00				
H3664	017	0	1	02	01	H3664_017_0	6	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					6.00	12.00	18.00																						6.00	12.00	18.00																		6.00					6.00							
H3664	017	0	1	02	01	H3664_017_0	6	4	Specialty Tier	1	4	000010	1	1	111100000010111000000001	30	60	90							1	30	60	90							30				31	14					1217.45	33	33	33																					33	33	33																	33							33			
H3664	018	0	1	02	01	H3664_018_0	6	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	285.00																		95.00								95.00				
H3664	018	0	1	02	01	H3664_018_0	6	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	135.00																		45.00								45.00				
H3664	018	0	1	02	01	H3664_018_0	6	1	Generic	1	4	010000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		31	14				9.00	18.00	27.00																						9.00	18.00	27.00																		9.00					9.00							
H3664	018	0	1	02	01	H3664_018_0	6	4	Specialty Tier	1	4	000010	1	1	111100000010111000000001	30	60	90							1	30	60	90							30				31	14					1697.07	33	33	33																					33	33	33																	33							33			
H3668	005	0	1	01	01	H3668_005_0	5	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		31	1	31	14		50.00	100.00	150.00																						50.00	100.00	100.00																		50.00					50.00			50.00				
H3668	005	0	1	01	01	H3668_005_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		31	1	31	14					660.00	33																							33																			33				33			33			
H3668	005	0	1	01	01	H3668_005_0	5	1	Preferred Generic	3	4	001001	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		31	1	31	14		0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00			0.00		1		
H3668	005	0	1	01	01	H3668_005_0	5	2	Non-Preferred Generic	3	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		31	1	31	14		10.00	20.00	30.00																						10.00	20.00	20.00																		10.00					10.00			10.00		1		
H3668	005	0	1	01	01	H3668_005_0	5	1	Preferred Generic	1	4	001001	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		31	1	31	14		0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00			0.00				
H3668	005	0	1	01	01	H3668_005_0	5	2	Non-Preferred Generic	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		31	1	31	14		10.00	20.00	30.00																						10.00	20.00	20.00																		10.00					10.00			10.00				
H3668	005	0	1	01	01	H3668_005_0	5	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		31	1	31	14		38.00	76.00	114.00																						38.00	76.00	76.00																		38.00					38.00			38.00				
H3668	011	0	1	01	01	H3668_011_0	4	1	Preferred Generic	1	4	001001	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		31	1	31	14		0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00			0.00				
H3668	011	0	1	01	01	H3668_011_0	4	2	Non-Preferred Generic	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		31	1	31	14		12.00	24.00	36.00																						12.00	24.00	24.00																		12.00					12.00			12.00				
H3668	011	0	1	01	01	H3668_011_0	4	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		31	1	31	14		45.00	90.00	135.00																						45.00	90.00	90.00																		45.00					45.00			45.00				
H3668	011	0	1	01	01	H3668_011_0	4	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		31	1	31	14		75.00	150.00	225.00																						75.00	150.00	150.00																		75.00					75.00			75.00				
H3668	011	0	1	01	01	H3668_011_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		31	1	31	14					1024.00	33																							33																			33				33			33			
H3668	011	0	1	01	01	H3668_011_0	4	1	Preferred Generic	3	4	001001	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		31	1	31	14		0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00			0.00		1		
H3668	014	0	1	01	01	H3668_014_0	5	2	Non-Preferred Generic	3	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		31	1	31	14		10.00	20.00	30.00																						10.00	20.00	20.00																		10.00					10.00			10.00		1		
H3668	014	0	1	01	01	H3668_014_0	5	1	Preferred Generic	3	4	001001	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		31	1	31	14		0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00			0.00		1		
H3668	014	0	1	01	01	H3668_014_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		31	1	31	14					660.00	33																							33																			33				33			33			
H3668	014	0	1	01	01	H3668_014_0	5	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		31	1	31	14		50.00	100.00	150.00																						50.00	100.00	100.00																		50.00					50.00			50.00				
H3668	014	0	1	01	01	H3668_014_0	5	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		31	1	31	14		38.00	76.00	114.00																						38.00	76.00	76.00																		38.00					38.00			38.00				
H3668	014	0	1	01	01	H3668_014_0	5	1	Preferred Generic	1	4	001001	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		31	1	31	14		0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00			0.00				
H3668	014	0	1	01	01	H3668_014_0	5	2	Non-Preferred Generic	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		31	1	31	14		10.00	20.00	30.00																						10.00	20.00	20.00																		10.00					10.00			10.00				
H3668	015	0	1	01	01	H3668_015_0	5	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		31	1	31	14		45.00	90.00	135.00																						45.00	90.00	90.00																		45.00					45.00			45.00				
H3668	015	0	1	01	01	H3668_015_0	5	2	Non-Preferred Generic	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		31	1	31	14		12.00	24.00	36.00																						12.00	24.00	24.00																		12.00					12.00			12.00				
H3668	015	0	1	01	01	H3668_015_0	5	1	Preferred Generic	1	4	001001	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		31	1	31	14		0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00			0.00				
H3668	015	0	1	01	01	H3668_015_0	5	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		31	1	31	14		75.00	150.00	225.00																						75.00	150.00	150.00																		75.00					75.00			75.00				
H3668	015	0	1	01	01	H3668_015_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		31	1	31	14					1024.00	33																							33																			33				33			33			
H3668	015	0	1	01	01	H3668_015_0	5	1	Preferred Generic	3	4	001001	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		31	1	31	14		0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00			0.00		1		
H3668	016	0	1	01	01	H3668_016_0	5	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		31	1	31	14		38.00	76.00	114.00																						38.00	76.00	76.00																		38.00					38.00			38.00				
H3668	016	0	1	01	01	H3668_016_0	5	2	Non-Preferred Generic	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		31	1	31	14		10.00	20.00	30.00																						10.00	20.00	20.00																		10.00					10.00			10.00				
H3668	016	0	1	01	01	H3668_016_0	5	1	Preferred Generic	1	4	001001	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		31	1	31	14		0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00			0.00				
H3668	016	0	1	01	01	H3668_016_0	5	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		31	1	31	14		50.00	100.00	150.00																						50.00	100.00	100.00																		50.00					50.00			50.00				
H3668	016	0	1	01	01	H3668_016_0	5	2	Non-Preferred Generic	3	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		31	1	31	14		10.00	20.00	30.00																						10.00	20.00	20.00																		10.00					10.00			10.00		1		
H3668	016	0	1	01	01	H3668_016_0	5	1	Preferred Generic	3	4	001001	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		31	1	31	14		0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00			0.00		1		
H3668	016	0	1	01	01	H3668_016_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		31	1	31	14					660.00	33																							33																			33				33			33			
H3668	017	0	1	01	01	H3668_017_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		31	1	31	14					1024.00	33																							33																			33				33			33			
H3668	017	0	1	01	01	H3668_017_0	5	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		31	1	31	14		75.00	150.00	225.00																						75.00	150.00	150.00																		75.00					75.00			75.00				
H3668	017	0	1	01	01	H3668_017_0	5	1	Preferred Generic	1	4	001001	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		31	1	31	14		0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00			0.00				
H3668	017	0	1	01	01	H3668_017_0	5	2	Non-Preferred Generic	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		31	1	31	14		12.00	24.00	36.00																						12.00	24.00	24.00																		12.00					12.00			12.00				
H3668	017	0	1	01	01	H3668_017_0	5	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		31	1	31	14		45.00	90.00	135.00																						45.00	90.00	90.00																		45.00					45.00			45.00				
H3668	017	0	1	01	01	H3668_017_0	5	1	Preferred Generic	3	4	001001	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		31	1	31	14		0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00			0.00		1		
H3672	013	0	1	01	01	H3672_013_0	9	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				8.00		24.00																								16.00																		8.00					8.00					1		
H3672	013	0	1	01	01	H3672_013_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		31	14	31	14					1000.16	33																							33																			33				33			33			
H3672	013	0	1	01	01	H3672_013_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							2			90							30				31	14		95.00		285.00																								190.00																		95.00								95.00				
H3672	013	0	1	01	01	H3672_013_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		40.00		120.00																								80.00																		40.00								40.00				
H3672	013	0	1	01	01	H3672_013_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				15.00		45.00																								30.00																		15.00					15.00							
H3672	013	0	1	01	01	H3672_013_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				8.00		24.00																								16.00																		8.00					8.00							
H3672	013	0	1	01	01	H3672_013_0	9	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				15.00		45.00																								30.00																		15.00					15.00					1		
H3672	016	0	1	01	01	H3672_016_0	8	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				3.00		9.00																								6.00																		3.00					3.00					1		
H3672	016	0	1	01	01	H3672_016_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		31	14	31	14					1023.52	33																							33																			33				33			33			
H3672	016	0	1	01	01	H3672_016_0	8	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							2			90							30				31	14		95.00		285.00																								190.00																		95.00								95.00				
H3672	016	0	1	01	01	H3672_016_0	8	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		35.00		105.00																								70.00																		35.00								35.00				
H3672	016	0	1	01	01	H3672_016_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				10.00		30.00																								20.00																		10.00					10.00							
H3672	016	0	1	01	01	H3672_016_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				3.00		9.00																								6.00																		3.00					3.00							
H3672	016	0	1	01	01	H3672_016_0	8	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				10.00		30.00																								20.00																		10.00					10.00					1		
H3706	001	0	1	01	01	H3706_001_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		40.00		100.00																													40.00		80.00					40.00		100.00				40.00								40.00				
H3706	001	0	1	01	01	H3706_001_0	6	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		7.00		17.50																													7.00		14.00					7.00		17.50				7.00					7.00			7.00				
H3706	001	0	1	01	01	H3706_001_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					2.00		5.00																													2.00		4.00					2.00		5.00				2.00					2.00							
H3706	001	0	1	01	01	H3706_001_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		80.00		200.00																													80.00		160.00					80.00		200.00				80.00								80.00				
H3706	001	0	1	01	01	H3706_001_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					500.00	33																														33							33					33				33			33			
H3706	017	0	1	01	01	H3706_017_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					2.00		5.00																													2.00		4.00					2.00		5.00				2.00					2.00							
H3706	017	0	1	01	01	H3706_017_0	7	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		7.00		17.50																													7.00		14.00					7.00		17.50				7.00					7.00			7.00				
H3706	017	0	1	01	01	H3706_017_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		40.00		100.00																													40.00		80.00					40.00		100.00				40.00								40.00				
H3706	017	0	1	01	01	H3706_017_0	7	1	Preferred Generic	3	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					2.00		5.00																													2.00		4.00					2.00		5.00				2.00					2.00					1		
H3706	017	0	1	01	01	H3706_017_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					500.00	33																														33							33					33				33			33			
H3706	017	0	1	01	01	H3706_017_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		80.00		200.00																													80.00		160.00					80.00		200.00				80.00								80.00				
H3706	017	0	1	01	01	H3706_017_0	7	2	Non-Preferred Generic	3	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		7.00		17.50																													7.00		14.00					7.00		17.50				7.00					7.00			7.00		1		
H3706	017	0	1	01	01	H3706_017_0	7	3	Preferred Brand	3	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		40.00		100.00																													40.00		80.00					40.00		100.00				40.00								40.00		2		
H3712	001	0	1	01	01	H3712_001_0	12	5	Specialty Tier	1	4	010010	1	1	110000000010000000000111	30																			30		31	14	31	14					333.36	33																																										33				33			33			
H3712	001	0	1	01	01	H3712_001_0	12	4	Non-Preferred Brand	1	4	100000	3	2	110100000010001000000001	30		90							1			90							30				31	14		20.00		60.00																								60.00																		20.00								20.00				
H3712	001	0	1	01	01	H3712_001_0	12	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00				
H3712	001	0	1	01	01	H3712_001_0	12	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H3712	001	0	1	01	01	H3712_001_0	12	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H3712	001	0	1	01	01	H3712_001_0	12	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H3712	001	0	1	01	01	H3712_001_0	12	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00		1		
H3712	001	0	1	01	01	H3712_001_0	12	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H3712	002	0	1	01	01	H3712_002_0	12	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H3712	002	0	1	01	01	H3712_002_0	12	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H3712	002	0	1	01	01	H3712_002_0	12	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H3712	002	0	1	01	01	H3712_002_0	12	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		25.00		75.00																								75.00																		25.00								25.00				
H3712	002	0	1	01	01	H3712_002_0	12	5	Specialty Tier	1	4	010010	1	1	110000000010000000000111	30																			30		31	14	31	14					333.37	33																																										33				33			33			
H3712	002	0	1	01	01	H3712_002_0	12	4	Non-Preferred Brand	1	4	100000	3	2	110100000010001000000001	30		90							1			90							30				31	14		45.00		135.00																								135.00																		45.00								45.00				
H3749	001	0	1	01	01	H3749_001_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H3749	001	0	1	01	01	H3749_001_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					536.00	33		33																														33							33			33				33			33			
H3749	001	0	1	01	01	H3749_001_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H3749	001	0	1	01	01	H3749_001_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H3749	001	0	1	01	01	H3749_001_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H3749	004	0	1	01	01	H3749_004_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H3749	004	0	1	01	01	H3749_004_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H3749	004	0	1	01	01	H3749_004_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H3749	004	0	1	01	01	H3749_004_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H3749	004	0	1	01	01	H3749_004_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					290.00	33		33																														33							33			33				33			33			
H3749	017	0	1	01	01	H3749_017_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H3749	017	0	1	01	01	H3749_017_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H3749	017	0	1	01	01	H3749_017_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H3749	017	0	1	01	01	H3749_017_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H3749	017	0	1	01	01	H3749_017_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					642.00	33		33																														33							33			33				33			33			
H3755	001	0	1	01	01	H3755_001_0	5	6	Injectable Drugs	1	4	100000	1	1	110100000010101000000001	30		90							1	30		90							30				31	7					43.62	33		33																					33		33																	33							33			
H3755	001	0	1	01	01	H3755_001_0	5	5	Specialty Tier	1	4	100000	1	1	110100000010101000000001	30		90							1	30		90							30				31	7					417.98	33		33																					33		33																	33							33			
H3755	001	0	1	01	01	H3755_001_0	5	4	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							1	30		90							30		31		31	7		95.00		285.00																						95.00		285.00																		95.00					95.00			95.00				
H3755	001	0	1	01	01	H3755_001_0	5	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							1	30		90							30				31	7		40.00		120.00																						40.00		120.00																		40.00								40.00				
H3755	001	0	1	01	01	H3755_001_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							1	30		90							30		31					12.00		36.00																						12.00		36.00																		12.00					12.00							
H3755	001	0	1	01	01	H3755_001_0	5	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							1	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00							
H3755	004	0	1	01	01	H3755_004_0	4	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							1	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00							
H3755	004	0	1	01	01	H3755_004_0	4	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							1	30		90							30		31					12.00		36.00																						12.00		36.00																		12.00					12.00							
H3755	004	0	1	01	01	H3755_004_0	4	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							1	30		90							30				31	7		40.00		120.00																						40.00		120.00																		40.00								40.00				
H3755	004	0	1	01	01	H3755_004_0	4	4	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							1	30		90							30		31		31	7		95.00		285.00																						95.00		285.00																		95.00					95.00			95.00				
H3755	004	0	1	01	01	H3755_004_0	4	5	Specialty Tier	1	4	100000	1	1	110100000010101000000001	30		90							1	30		90							30				31	7					241.07	33		33																					33		33																	33							33			
H3755	004	0	1	01	01	H3755_004_0	4	6	Injectable Drugs	1	4	100000	1	1	110100000010101000000001	30		90							1	30		90							30				31	7					64.17	33		33																					33		33																	33							33			
H3805	001	0	1	01	01	H3805_001_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					369.00	33		33																														33							33			33				33			33			
H3805	001	0	1	01	01	H3805_001_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		88.00		264.00																															254.00							264.00				88.00					88.00			88.00				
H3805	001	0	1	01	01	H3805_001_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H3805	001	0	1	01	01	H3805_001_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H3805	001	0	1	01	01	H3805_001_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		44.00		132.00																															122.00							132.00				44.00					44.00			44.00				
H3805	007	0	1	01	01	H3805_007_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					522.00	33		33																														33							33			33				33			33			
H3805	007	0	1	01	01	H3805_007_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		88.00		264.00																															254.00							264.00				88.00					88.00			88.00				
H3805	007	0	1	01	01	H3805_007_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		44.00		132.00																															122.00							132.00				44.00					44.00			44.00				
H3805	007	0	1	01	01	H3805_007_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H3805	007	0	1	01	01	H3805_007_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H3805	012	0	1	01	01	H3805_012_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H3805	012	0	1	01	01	H3805_012_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H3805	012	0	1	01	01	H3805_012_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					7.00		21.00																															14.00							21.00				7.00					7.00							
H3805	012	0	1	01	01	H3805_012_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					4.00		12.00																															8.00							12.00				4.00					4.00							
H3805	012	0	1	01	01	H3805_012_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					369.00	33		33																														33							33			33				33			33			
H3805	013	0	1	01	01	H3805_013_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H3805	013	0	1	01	01	H3805_013_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H3805	013	0	1	01	01	H3805_013_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					7.00		21.00																															14.00							21.00				7.00					7.00							
H3805	013	0	1	01	01	H3805_013_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					4.00		12.00																															8.00							12.00				4.00					4.00							
H3805	013	0	1	01	01	H3805_013_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					522.00	33		33																														33							33			33				33			33			
H3810	003	0	1	01	01	H3810_003_0	12	5	Specialty Tier	1	4	101101	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		31	14	31	14					33.00	33	33	33																					33	33	33																	33				33			33			
H3810	003	0	1	01	01	H3810_003_0	12	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		31	14				10.00	20.00	20.00																						10.00	20.00	20.00																		10.00					10.00					1		
H3810	003	0	1	01	01	H3810_003_0	12	4	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		69.00	138.00	138.00																						69.00	138.00	138.00																		69.00								69.00				
H3810	003	0	1	01	01	H3810_003_0	12	3	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		39.00	78.00	78.00																						39.00	78.00	78.00																		39.00								39.00				
H3810	003	0	1	01	01	H3810_003_0	12	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		31	14				29.00	58.00	58.00																						29.00	58.00	58.00																		29.00					29.00							
H3810	003	0	1	01	01	H3810_003_0	12	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		31	14				5.00	10.00	10.00																						5.00	10.00	10.00																		5.00					5.00							
H3810	005	0	1	02	01	H3810_005_0	10	1	Preferred Generic	3	4	001000	1	2	011100000001111000000110	30	60	90							1	30	60	90								29	31	14				10.00	20.00	20.00																						10.00	20.00	20.00																			10.00				10.00					1		
H3810	005	0	1	02	01	H3810_005_0	10	1	Preferred Generic	1	4	001000	1	2	011100000001111000000110	30	60	90							1	30	60	90								29	31	14				5.00	10.00	10.00																						5.00	10.00	10.00																			5.00				5.00							
H3810	005	0	1	02	01	H3810_005_0	10	4	Non-Preferred Brand	1	4	100000	1	2	111100000001111000000001	30	60	90							1	30	60	90								29			31	14		69.00	138.00	138.00																						69.00	138.00	138.00																			69.00							69.00				
H3810	005	0	1	02	01	H3810_005_0	10	3	Preferred Brand	1	4	000001	1	2	111100000001111000000001	30	60	90							1	30	60	90								29			31	14		39.00	78.00	78.00																						39.00	78.00	78.00																			39.00							39.00				
H3810	005	0	1	02	01	H3810_005_0	10	2	Non-Preferred Generic	1	4	000100	1	2	011100000001111000000110	30	60	90							1	30	60	90								29	31	14				29.00	58.00	58.00																						29.00	58.00	58.00																			29.00				29.00							
H3810	005	0	1	02	01	H3810_005_0	10	5	Specialty Tier	1	4	101101	1	1	111100000001111000000111	30	60	90							1	30	60	90								29	31	14	31	14					33.00	33	33	33																					33	33	33																		33			33			33			
H3810	007	0	1	01	01	H3810_007_0	10	1	Preferred Generic	1	4	001000	1	2	011100000001111000000110	30	60	90							1	30	60	90								29	31	14				5.00	10.00	10.00																						5.00	10.00	10.00																			5.00				5.00							
H3810	007	0	1	01	01	H3810_007_0	10	2	Non-Preferred Generic	1	4	000100	1	2	011100000001111000000110	30	60	90							1	30	60	90								29	31	14				29.00	58.00	58.00																						29.00	58.00	58.00																			29.00				29.00							
H3810	007	0	1	01	01	H3810_007_0	10	3	Preferred Brand	1	4	000001	1	2	111100000001111000000001	30	60	90							1	30	60	90								29			31	14		39.00	78.00	78.00																						39.00	78.00	78.00																			39.00							39.00				
H3810	007	0	1	01	01	H3810_007_0	10	4	Non-Preferred Brand	1	4	100000	1	2	111100000001111000000001	30	60	90							1	30	60	90								29			31	14		69.00	138.00	138.00																						69.00	138.00	138.00																			69.00							69.00				
H3810	007	0	1	01	01	H3810_007_0	10	1	Preferred Generic	3	4	001000	1	2	011100000001111000000110	30	60	90							1	30	60	90								29	31	14				10.00	20.00	20.00																						10.00	20.00	20.00																			10.00				10.00					1		
H3810	007	0	1	01	01	H3810_007_0	10	5	Specialty Tier	1	4	101101	1	1	111100000001111000000111	30	60	90							1	30	60	90								29	31	14	31	14					33.00	33	33	33																					33	33	33																		33			33			33			
H3811	002	0	1	01	01	H3811_002_0	5	5	Specialty Tier	1	4	000001	1	1	110000000010000000000001	34																			34				31	1					60.98	30																																										30							30			
H3811	002	0	1	01	01	H3811_002_0	5	4	Non-Preferred Brand	1	4	100000	1	2	111100000010001000000001	34	60	90							2			90							34				31	1		80.00	160.00	240.00																								240.00																		80.00								80.00				
H3811	002	0	1	01	01	H3811_002_0	5	3	Preferred Brand	1	4	000001	1	2	111100000010001000000001	34	60	90							2			90							34				31	1		40.00	80.00	120.00																								120.00																		40.00								40.00				
H3811	002	0	1	01	01	H3811_002_0	5	2	Non-Preferred Generic	1	4	000100	1	2	011100000010001000000100	34	60	90							2			90							34		31					9.00	18.00	27.00																								27.00																		9.00					9.00							
H3811	002	0	1	01	01	H3811_002_0	5	1	Preferred Generic	1	4	001000	1	2	011100000010001000000100	34	60	90							1			90							34		31					0.00	0.00	0.00																								0.00																		0.00					0.00							
H3811	009	0	1	01	01	H3811_009_0	7	1	Preferred Generic	1	4	001000	1	2	011100000010001000000100	34	60	90							1			90							34		31					0.00	0.00	0.00																								0.00																		0.00					0.00							
H3811	009	0	1	01	01	H3811_009_0	7	2	Non-Preferred Generic	3	4	000100	1	2	011100000010001000000100	34	60	90							2			90							34		31					9.00	18.00	27.00																								27.00																		9.00					9.00					1		
H3811	009	0	1	01	01	H3811_009_0	7	2	Non-Preferred Generic	1	4	000100	1	2	011100000010001000000100	34	60	90							2			90							34		31					9.00	18.00	27.00																								27.00																		9.00					9.00							
H3811	009	0	1	01	01	H3811_009_0	7	3	Preferred Brand	1	4	000001	1	2	111100000010001000000001	34	60	90							2			90							34				31	1		40.00	80.00	120.00																								120.00																		40.00								40.00				
H3811	009	0	1	01	01	H3811_009_0	7	1	Preferred Generic	3	4	001000	1	2	011100000010001000000100	34	60	90							1			90							34		31					0.00	0.00	0.00																								0.00																		0.00					0.00					1		
H3811	009	0	1	01	01	H3811_009_0	7	5	Specialty Tier	1	4	000010	1	1	110000000010000000000001	34																			34				31	1					67.06	30																																										30							30			
H3811	009	0	1	01	01	H3811_009_0	7	4	Non-Preferred Brand	1	4	100000	1	2	111100000010001000000001	34	60	90							2			90							34				31	1		80.00	160.00	240.00																								240.00																		80.00								80.00				
H3812	001	0	1	04	01	H3812_001_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H3812	001	0	1	04	01	H3812_001_0	8	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H3812	001	0	1	04	01	H3812_001_0	8	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H3812	001	0	1	04	01	H3812_001_0	8	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					433.00	33		33																														33							33			33				33			33			
H3812	001	0	1	04	01	H3812_001_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H3813	003	0	1	04	01	H3813_003_0	4	1	Preferred Generic	1	3	001000		2	010100000010101000000110	31		93							1	31		93							31		31	14				5.00		15.00																						5.00		15.00																		5.00					5.00							
H3813	003	0	1	04	01	H3813_003_0	4	2	Non-Preferred Generic	1	3	000100		2	010100000010101000000110	31		93							1	31		93							31		31	14				33.00		99.00																						33.00		99.00																		33.00					33.00							
H3813	003	0	1	04	01	H3813_003_0	4	3	Preferred Brand	1	3	000001		2	110100000010101000000001	31		93							1	31		93							31				31	14		41.00		123.00																						41.00		123.00																		41.00								41.00				
H3813	003	0	1	04	01	H3813_003_0	4	4	Non-Preferred Brand	1	3	100000		1	110100000010101000000001	31		93							1	31		93							31				31	14					59.00	50		50																					50		50																	50							50			
H3813	003	0	1	04	01	H3813_003_0	4	5	Specialty Tier	1	3	100000		1	110000000010100000000001	31										31									31				31	14					505.00	30																							30																			30							30			
H3813	004	0	1	04	01	H3813_004_0	4	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	31		93							1	31		93							31		31					5.00		15.00																						5.00		15.00																		5.00					5.00							
H3813	004	0	1	04	01	H3813_004_0	4	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	31		93							1	31		93							31		31					33.00		99.00																						33.00		99.00																		33.00					33.00							
H3813	004	0	1	04	01	H3813_004_0	4	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		93							1	31		93							31				31	14		40.00		120.00																						40.00		120.00																		40.00								40.00				
H3813	004	0	1	04	01	H3813_004_0	4	4	Non-Preferred Brand	1	4	100000	1	1	110100000010101000000001	31		93							1	31		93							31				31	14					59.00	50		50																					50		50																	50							50			
H3813	004	0	1	04	01	H3813_004_0	4	5	Specialty Tier	1	4	100000	1	1	110000000010100000000001	31										31									31				31	14					555.00	33																							33																			33							33			
H3813	005	0	1	04	01	H3813_005_0	4	4	Non-Preferred Brand	1	4	100000	1	1	110100000010101000000001	31		93							1	31		93							31				31	14					59.00	50		50																					50		50																	50							50			
H3813	005	0	1	04	01	H3813_005_0	4	5	Specialty Tier	1	4	100000	1	1	110000000010100000000001	31										31									31				31	14					555.00	33																							33																			33							33			
H3813	005	0	1	04	01	H3813_005_0	4	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	31		93							1	31		93							31		31					5.00		15.00																						5.00		15.00																		5.00					5.00							
H3813	005	0	1	04	01	H3813_005_0	4	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	31		93							1	31		93							31		31					33.00		99.00																						33.00		99.00																		33.00					33.00							
H3813	005	0	1	04	01	H3813_005_0	4	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		93							1	31		93							31				31	14		40.00		120.00																						40.00		120.00																		40.00								40.00				
H3813	006	0	1	04	01	H3813_006_0	5	1	Preferred Generic	1	3	001000		2	010100000010101000000100	31		93							1	31		93							31		31					5.00		15.00																						5.00		15.00																		5.00					5.00							
H3813	006	0	1	04	01	H3813_006_0	5	5	Specialty Tier	1	3	100000		1	110000000010100000000001	31										31									31				31	14					505.00	30																							30																			30							30			
H3813	006	0	1	04	01	H3813_006_0	5	2	Non-Preferred Generic	1	3	000100		2	010100000010101000000100	31		93							1	31		93							31		31					33.00		99.00																						33.00		99.00																		33.00					33.00							
H3813	006	0	1	04	01	H3813_006_0	5	3	Preferred Brand	1	3	000001		2	110100000010101000000001	31		93							1	31		93							31				31	14		41.00		123.00																						41.00		123.00																		41.00								41.00				
H3813	006	0	1	04	01	H3813_006_0	5	4	Non-Preferred Brand	1	3	100000		1	110100000010101000000001	31		93							1	31		93							31				31	14					59.00	50		50																					50		50																	50							50			
H3815	001	0	1	01	01	H3815_001_0	9	4	Injectable Drugs	1	4	010010	1	1	111100000001001000000101	30	60	90							1			90								20	31		31	14					25.00	25	25	25																							25																		25			25			25			
H3815	001	0	1	01	01	H3815_001_0	9	5	Specialty Tier	1	4	010010	1	1	110000000001000000000101	30																				20	31		31	14					33.00	33																																											33			33			33			
H3815	001	0	1	01	01	H3815_001_0	9	1	Generic	1	4	010000	1	2	011100000001001000000100	30	60	90							1			90								20	31					0.00	0.00	0.00																								0.00																			0.00				0.00							
H3815	001	0	1	01	01	H3815_001_0	9	3	Non-Preferred Brand	1	4	100000	3	2	111100000001001000000001	30	60	90							1			90								20			31	14		60.00	120.00	180.00																								120.00																			60.00							60.00				
H3815	001	0	1	01	01	H3815_001_0	9	2	Preferred Brand	1	4	000001	1	2	111100000001001000000001	30	60	90							1			90								20			31	14		15.00	30.00	45.00																								30.00																			15.00							15.00				
H3815	001	0	1	01	01	H3815_001_0	9	1	Generic	3	4	010000	1	2	011100000001001000000100	30	60	90							1			90								20	31					0.00	0.00	0.00																								0.00																			0.00				0.00					1		
H3815	006	0	1	01	01	H3815_006_0	9	3	Non-Preferred Brand	1	4	100000	3	2	111100000001001000000001	30	60	90							1			90								20			31	14		60.00	120.00	180.00																								120.00																			60.00							60.00				
H3815	006	0	1	01	01	H3815_006_0	9	1	Generic	1	4	010000	1	2	011100000001001000000100	30	60	90							1			90								20	31					0.00	0.00	0.00																								0.00																			0.00				0.00							
H3815	006	0	1	01	01	H3815_006_0	9	5	Specialty Tier	1	4	010010	1	1	110000000001000000000101	30																				20	31		31	14					33.00	33																																											33			33			33			
H3815	006	0	1	01	01	H3815_006_0	9	4	Injectable Drugs	1	4	010010	1	1	111100000001001000000101	30	60	90							1			90								20	31		31	14					25.00	25	25	25																							25																		25			25			25			
H3815	006	0	1	01	01	H3815_006_0	9	1	Generic	3	4	010000	1	2	011100000001001000000100	30	60	90							1			90								20	31					0.00	0.00	0.00																								0.00																			0.00				0.00					1		
H3815	006	0	1	01	01	H3815_006_0	9	2	Preferred Brand	1	4	000001	1	2	111100000001001000000001	30	60	90							1			90								20			31	14		15.00	30.00	45.00																								30.00																			15.00							15.00				
H3817	002	0	1	04	01	H3817_002_0	9	1	Preferred Generic	1	3	001000		2	010100000010101000000100	30		90							1	30		90							30		31				0.25	7.50		22.50																					0.25	7.50		15.00																		7.50				0.24	7.50							
H3817	002	0	1	04	01	H3817_002_0	9	6	Injectable Drugs	1	3	101101		1	110000000010100000000101	30										30									30		31		31	14					50.00	29																							29																			29				29			29			
H3817	002	0	1	04	01	H3817_002_0	9	2	Non-Preferred Generic	1	3	000100		2	010100000010101000000100	30		90							1	30		90							30		31				1.10	33.00		99.00																					1.10	33.00		66.00																		33.00				1.06	33.00							
H3817	002	0	1	04	01	H3817_002_0	9	4	Non-Preferred Brand	1	3	100000		2	110100000010101000000001	30		90							1	30		90							30				31	14	3.00	90.00		270.00																					3.00	90.00		225.00																		90.00							2.90	90.00				
H3817	002	0	1	04	01	H3817_002_0	9	5	Specialty Tier	1	3	101101		1	110000000010100000000101	30										30									30		31		31	14					372.00	29																							29																			29				29			29			
H3817	002	0	1	04	01	H3817_002_0	9	3	Preferred Brand	1	3	000001		2	110100000010101000000001	30		90							1	30		90							30				31	14	1.50	45.00		135.00																					1.50	45.00		112.50																		45.00							1.45	45.00				
H3817	003	0	1	04	01	H3817_003_0	10	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		90							1	30		90							30		31				0.16	5.00		15.00																					0.16	5.00		10.00																		5.00				0.16	5.00					1		
H3817	003	0	1	04	01	H3817_003_0	10	6	Injectable Drugs	1	4	101101	1	1	110000000010100000000101	30										30									30		31		31	14					59.00	33																							33																			33				33			33			
H3817	003	0	1	04	01	H3817_003_0	10	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							1	30		90							30				31	14	3.00	90.00		270.00																					3.00	90.00		225.00																		90.00							2.90	90.00				
H3817	003	0	1	04	01	H3817_003_0	10	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							1	30		90							30				31	14	1.50	45.00		135.00																					1.50	45.00		112.50																		45.00							1.45	45.00				
H3817	003	0	1	04	01	H3817_003_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							1	30		90							30		31				1.10	33.00		99.00																					1.10	33.00		66.00																		33.00				1.06	33.00							
H3817	003	0	1	04	01	H3817_003_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							1	30		90							30		31				0.16	5.00		15.00																					0.16	5.00		10.00																		5.00				0.16	5.00							
H3817	003	0	1	04	01	H3817_003_0	10	5	Specialty Tier	1	4	101101	1	1	110000000010100000000101	30										30									30		31		31	14					460.00	33																							33																			33				33			33			
H3818	003	0	1	01	01	H3818_003_0	10	4	Specialty Tier	1	3	100101		1	110100000001101000000101	30		90							1	30		90								10	31		31	10					28.00	28		28																					28		28																		28			28			28			
H3818	003	0	1	01	01	H3818_003_0	10	3	Non-Preferred Brand	1	3	100000		2	110100000001101000000001	30		90							1	30		90								10			31	10		70.00		210.00																						70.00		140.00																			70.00							70.00				
H3818	003	0	1	01	01	H3818_003_0	10	2	Preferred Brand	1	3	000101		2	110100000001101000000101	30		90							1	30		90								10	31		31	10		30.00		90.00																						30.00		60.00																			30.00				30.00			30.00				
H3818	003	0	1	01	01	H3818_003_0	10	1	Preferred Generic	1	3	001000		2	010100000001101000000100	30		90							1	30		90								10	31					7.00		21.00																						7.00		14.00																			7.00				7.00							
H3818	014	0	1	01	01	H3818_014_0	10	3	Non-Preferred Brand	1	4	100000	1	2	110100000001101000000001	30		90							1	30		90								10			31	10		70.00		210.00																						70.00		140.00																			70.00						0.00	70.00				
H3818	014	0	1	01	01	H3818_014_0	10	2	Preferred Brand	1	4	001001	1	2	110100000001101000000101	30		90							1	30		90								10	31		31	10		30.00		90.00																						30.00		60.00																			30.00				30.00			30.00				
H3818	014	0	1	01	01	H3818_014_0	10	1	Preferred Generic	1	4	001000	1	2	010100000001101000000100	30		90							1	30		90								10	31					7.00		21.00																						7.00		14.00																			7.00				7.00							
H3818	014	0	1	01	01	H3818_014_0	10	4	Specialty Tier	1	4	101001	1	1	110100000001101000000101	30		90							1	30		90								10	31		31	10					30.00	30		30																					30		30																		30			30			30			
H3822	001	0	1	01	01	H3822_001_0	9	4	Non-Preferred Brand	1	3	100000		2	100010110110001000000001				30		90	30		90	1			90							30				31	14										95.00		237.50						95.00		285.00								237.50																		95.00								95.00				
H3822	001	0	1	01	01	H3822_001_0	9	3	Preferred Brand	1	3	000001		2	100010110110001000000001				30		90	30		90	1			90							30				31	14										45.00		112.50						45.00		135.00								112.50																		45.00								45.00				
H3822	001	0	1	01	01	H3822_001_0	9	2	Non-Preferred Generic	1	3	000100		2	000010110110001000000100				30		90	30		90	1			90							30		31													11.00		27.50						11.00		33.00								27.50																		11.00					11.00							
H3822	001	0	1	01	01	H3822_001_0	9	1	Preferred Generic	1	3	001000		2	000010110110001000000100				30		90	30		90	1			90							30		31													3.00		7.50						3.00		9.00								7.50																		3.00					3.00							
H3822	001	0	1	01	01	H3822_001_0	9	5	Specialty Tier	1	3	010010		1	100010110110000000000101				30		90	30		90	1										30		31		31	14													940.00	25		25					940.00	25		25																								25				25			25			
H3822	002	0	1	01	01	H3822_002_0	7	4	Non-Preferred Brand	1	3	100000		2	100010110110001000000001				30		90	30		90	1			90							30				31	14										95.00		237.50						95.00		285.00								237.50																		95.00								95.00				
H3822	002	0	1	01	01	H3822_002_0	7	3	Preferred Brand	1	3	000001		2	100010110110001000000001				30		90	30		90	1			90							30				31	14										45.00		112.50						45.00		135.00								112.50																		45.00								45.00				
H3822	002	0	1	01	01	H3822_002_0	7	2	Non-Preferred Generic	1	3	000100		2	000010110110001000000100				30		90	30		90	1			90							30		31													12.00		30.00						12.00		36.00								30.00																		12.00					12.00							
H3822	002	0	1	01	01	H3822_002_0	7	1	Preferred Generic	1	3	001000		2	000010110110001000000100				30		90	30		90	1			90							30		31													3.00		7.50						3.00		9.00								7.50																		3.00					3.00							
H3822	002	0	1	01	01	H3822_002_0	7	5	Specialty Tier	1	3	010010		1	100010110110000000000101				30		90	30		90	1										30		31		31	14													1030.00	25		25					1030.00	25		25																								25				25			25			
H3832	001	0	1	04	01	H3832_001_0	10	1	Generic	1	4	010000	1	2	010100000010001000000100	30		90							2			90							30		34					4.00		12.00																								4.00																		4.00					4.00							
H3832	001	0	1	04	01	H3832_001_0	10	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				34	14		30.00		90.00																								60.00																		30.00								30.00				
H3832	001	0	1	04	01	H3832_001_0	10	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							2			90							30				34	14		65.00		195.00																								130.00																		65.00								65.00				
H3832	001	0	1	04	01	H3832_001_0	10	4	Specialty Tier	1	4	010010	1	1	110100000010000000000101	30		90							2										30		34		34	14					382.76	25		25																																								25				25			25			
H3832	001	0	1	04	01	H3832_001_0	10	1	Generic	3	4	010000	1	2	010100000010001000000100	30		90							2			90							30		34					4.00		12.00																								4.00																		4.00					4.00					1		
H3832	006	0	1	04	01	H3832_006_0	8	1	Generic	1	4	010000	1	2	010100000010001000000100	30		90							2			90							30		34					4.00		12.00																								4.00																		4.00					4.00							
H3832	006	0	1	04	01	H3832_006_0	8	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				34	14		30.00		90.00																								60.00																		30.00								30.00				
H3832	006	0	1	04	01	H3832_006_0	8	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							2			90							30				34	14		65.00		195.00																								130.00																		65.00								65.00				
H3832	006	0	1	04	01	H3832_006_0	8	4	Specialty Tier	1	4	010010	1	1	110100000010000000000101	30		90							2										30		34		34	14					293.53	25		25																																								25				25			25			
H3832	006	0	1	04	01	H3832_006_0	8	1	Generic	3	4	010000	1	2	010100000010001000000100	30		90							2			90							30		34					4.00		12.00																								4.00																		4.00					4.00			4.00		1		
H3864	006	0	1	01	01	H3864_006_0	12	4	Specialty Tier	1	4	110001	1	1	110000000010000000000101	31																			31		31		31	14					903.00	33																																										33				33			33			
H3864	006	0	1	01	01	H3864_006_0	12	1	Generic	1	4	010000	1	2	010100000010101000000100	31		93							2	31		93							31		31					5.00		10.00																						5.00		10.00																		5.00					5.00							
H3864	006	0	1	01	01	H3864_006_0	12	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		93							2	31		93							31				31	14		35.00		87.50																						35.00		87.50																		35.00								35.00				
H3864	006	0	1	01	01	H3864_006_0	12	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		93							2	31		93							31				31	14		80.00		240.00																						80.00		240.00																		80.00								80.00				
H3864	014	0	1	01	01	H3864_014_0	9	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		93							2	31		93							31				31	14		85.00		255.00																						85.00		255.00																		85.00								85.00				
H3864	014	0	1	01	01	H3864_014_0	9	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		93							2	31		93							31				31	14		40.00		100.00																						40.00		100.00																		40.00								40.00				
H3864	014	0	1	01	01	H3864_014_0	9	1	Generic	1	4	010000	1	2	010100000010101000000100	31		93							2	31		93							31		31					8.00		16.00																						8.00		16.00																		8.00					8.00							
H3864	014	0	1	01	01	H3864_014_0	9	4	Specialty Tier	1	4	110001	1	1	110000000010000000000101	31																			31		31		31	14					903.00	33																																										33				33			33			
H3864	015	0	1	01	01	H3864_015_0	7	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		93							2	31		93							31				31	14		40.00		100.00																						40.00		100.00																		40.00								40.00				
H3864	015	0	1	01	01	H3864_015_0	7	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		93							2	31		93							31				31	14		80.00		240.00																						80.00		240.00																		80.00								80.00				
H3864	015	0	1	01	01	H3864_015_0	7	4	Specialty Tier	1	4	110001	1	1	110000000010000000000101	31																			31		31		31	14					903.00	33																																										33				33			33			
H3864	015	0	1	01	01	H3864_015_0	7	1	Generic	1	4	010000	1	2	010100000010101000000100	31		93							2	31		93							31		31					5.00		10.00																						5.00		10.00																		5.00					5.00							
H3864	016	0	1	01	01	H3864_016_0	9	4	Specialty Tier	1	4	110001	1	1	110000000010000000000101	31																			31		31		31	14					903.00	33																																										33				33			33			
H3864	016	0	1	01	01	H3864_016_0	9	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		93							2	31		93							31				31	14		80.00		240.00																						80.00		240.00																		80.00								80.00				
H3864	016	0	1	01	01	H3864_016_0	9	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		93							2	31		93							31				31	14		40.00		100.00																						40.00		100.00																		40.00								40.00				
H3864	016	0	1	01	01	H3864_016_0	9	1	Generic	1	4	010000	1	2	010100000010101000000100	31		93							2	31		93							31		31					5.00		10.00																						5.00		10.00																		5.00					5.00							
H3864	019	0	1	01	01	H3864_019_0	7	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		93							2	31		93							31				31	14		88.00		264.00																						88.00		264.00																		88.00								88.00				
H3864	019	0	1	01	01	H3864_019_0	7	4	Specialty Tier	1	4	110001	1	1	110000000010000000000101	31																			31		31		31	14					903.00	33																																										33				33			33			
H3864	019	0	1	01	01	H3864_019_0	7	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		93							2	31		93							31				31	14		44.00		110.00																						44.00		110.00																		44.00								44.00				
H3864	019	0	1	01	01	H3864_019_0	7	1	Generic	1	4	010000	1	2	010100000010101000000100	31		93							2	31		93							31		31					7.00		14.00																						7.00		14.00																		7.00					7.00							
H3864	020	0	1	01	01	H3864_020_0	7	4	Specialty Tier	1	4	110001	1	1	110000000010000000000101	31																			31		31		31	14					903.00	33																																										33				33			33			
H3864	020	0	1	01	01	H3864_020_0	7	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		93							2	31		93							31				31	14		88.00		264.00																						88.00		264.00																		88.00								88.00				
H3864	020	0	1	01	01	H3864_020_0	7	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		93							2	31		93							31				31	14		44.00		110.00																						44.00		110.00																		44.00								44.00				
H3864	020	0	1	01	01	H3864_020_0	7	1	Generic	1	4	010000	1	2	010100000010101000000100	31		93							2	31		93							31		31					7.00		14.00																						7.00		14.00																		7.00					7.00							
H3864	021	0	1	01	01	H3864_021_0	7	1	Generic	1	4	010000	1	2	010100000010101000000100	31		93							2	31		93							31		31					7.00		14.00																						7.00		14.00																		7.00					7.00							
H3864	021	0	1	01	01	H3864_021_0	7	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		93							2	31		93							31				31	14		44.00		110.00																						44.00		110.00																		44.00								44.00				
H3864	021	0	1	01	01	H3864_021_0	7	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		93							2	31		93							31				31	14		88.00		264.00																						88.00		264.00																		88.00								88.00				
H3864	021	0	1	01	01	H3864_021_0	7	4	Specialty Tier	1	4	110001	1	1	110000000010000000000101	31																			31		31		31	14					903.00	33																																										33				33			33			
H3887	003	0	1	02	01	H3887_003_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H3887	003	0	1	02	01	H3887_003_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H3887	003	0	1	02	01	H3887_003_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					466.00	33		33																														33							33			33				33			33			
H3887	003	0	1	02	01	H3887_003_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H3887	003	0	1	02	01	H3887_003_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H3907	006	0	1	01	01	H3907_006_0	8	5	Select Care Drugs	1	3	010000		2	010100000010001000000110	31		90							1			90							31		31	14				0.00		0.00																								0.00																		0.00					0.00							
H3907	006	0	1	01	01	H3907_006_0	8	1	Generic	1	3	010000		2	010100000010001000000110	31		90							1			90							31		31	14				8.00		16.00																								16.00																		8.00					8.00							
H3907	006	0	1	01	01	H3907_006_0	8	4	Specialty Tier	1	3	010010		1	110000000010100000000111	31										31									31		31	14	31	14					760.00	33																							33																			33				33			33			
H3907	006	0	1	01	01	H3907_006_0	8	3	Non-Preferred Brand	1	3	100000		2	110100000010001000000001	31		90							1			90							31				31	14		95.00		285.00																								285.00																		95.00								95.00				
H3907	006	0	1	01	01	H3907_006_0	8	2	Preferred Brand	1	3	000001		2	110100000010001000000001	31		90							1			90							31				31	14		44.00		121.00																								110.00																		44.00								44.00				
H3907	029	0	1	01	01	H3907_029_0	11	2	Preferred Brand	1	3	000001		2	110100000010001000000001	31		90							1			90							31				31	14		44.00		121.00																								110.00																		44.00								44.00				
H3907	029	0	1	01	01	H3907_029_0	11	3	Non-Preferred Brand	1	3	100000		2	110100000010001000000001	31		90							1			90							31				31	14		95.00		285.00																								285.00																		95.00								95.00				
H3907	029	0	1	01	01	H3907_029_0	11	4	Specialty Tier	1	3	010010		1	110000000010100000000111	31										31									31		31	14	31	14					760.00	33																							33																			33				33			33			
H3907	029	0	1	01	01	H3907_029_0	11	5	Select Care Drugs	1	3	010000		2	010100000010001000000110	31		90							1			90							31		31	14				0.00		0.00																								0.00																		0.00					0.00							
H3907	029	0	1	01	01	H3907_029_0	11	1	Generic	1	3	010000		2	010100000010001000000110	31		90							1			90							31		31	14				8.00		16.00																								16.00																		8.00					8.00							
H3907	037	0	1	01	01	H3907_037_0	11	4	Specialty Tier	1	3	010010		1	110000000010100000000111	31										31									31		31	14	31	14					760.00	33																							33																			33				33			33			
H3907	037	0	1	01	01	H3907_037_0	11	5	Select Care Drugs	1	3	010000		2	010100000010001000000110	31		90							1			90							31		31	14				0.00		0.00																								0.00																		0.00					0.00							
H3907	037	0	1	01	01	H3907_037_0	11	3	Non-Preferred Brand	1	3	100000		2	110100000010001000000001	31		90							1			90							31				31	14		95.00		285.00																								285.00																		95.00								95.00				
H3907	037	0	1	01	01	H3907_037_0	11	2	Preferred Brand	1	3	000001		2	110100000010001000000001	31		90							1			90							31				31	14		44.00		121.00																								110.00																		44.00								44.00				
H3907	037	0	1	01	01	H3907_037_0	11	1	Generic	1	3	010000		2	010100000010001000000110	31		90							1			90							31		31	14				9.00		18.00																								18.00																		9.00					9.00							
H3909	001	0	1	04	01	H3909_001_0	7	1	Generic	1	3	010000		2	010100000010001000000110	30		90							1			90							30		31	14				5.00		15.00																								10.00																		5.00					5.00							
H3909	001	0	1	04	01	H3909_001_0	7	2	Preferred Brand	1	3	000001		2	110100000010001000000001	30		90							1			90							30				31	14		40.00		120.00																								80.00																		40.00								40.00				
H3909	001	0	1	04	01	H3909_001_0	7	3	Non-Preferred Brand	1	3	100000		2	110100000010001000000001	30		90							1			90							30				31	14		80.00		240.00																								160.00																		80.00								80.00				
H3909	001	0	1	04	01	H3909_001_0	7	4	Specialty Tier	1	3	100000		1	110100000010001000000001	30		90							1			90							30				31	14					220.34	25		25																							25																	25							25			
H3916	001	0	1	04	01	H3916_001_0	5	1	Generic	3	4	010000	1	1	010100000010001000000100	34		90							1			90							34		34								20.23	50		50																							50																	50				50				1		
H3916	001	0	1	04	01	H3916_001_0	5	1	Generic	1	4	010000	1	2	010100000010001000000100	34		90							1			90							34		34					8.00		24.00																								20.00																		8.00					8.00							
H3916	001	0	1	04	01	H3916_001_0	5	4	Specialty Tier	1	4	010010	1	1	110100000010001000000101	34		90							1			90							34		34		34	14					668.31	33		33																							33																	33				33			33			
H3916	001	0	1	04	01	H3916_001_0	5	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	34		90							1			90							34				34	14		90.00		270.00																								225.00																		90.00								90.00				
H3916	001	0	1	04	01	H3916_001_0	5	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	34		90							1			90							34				34	14		42.00		126.00																								105.00																		42.00								42.00				
H3916	002	0	1	04	01	H3916_002_0	5	1	Generic	3	4	010000	1	1	010100000010001000000100	34		90							1			90							34		34								18.42	50		50																							50																	50				50				1		
H3916	002	0	1	04	01	H3916_002_0	5	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	34		90							1			90							34				34	14		90.00		270.00																								225.00																		90.00								90.00				
H3916	002	0	1	04	01	H3916_002_0	5	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	34		90							1			90							34				34	14		42.00		126.00																								105.00																		42.00								42.00				
H3916	002	0	1	04	01	H3916_002_0	5	1	Generic	1	4	010000	1	2	010100000010001000000100	34		90							1			90							34		34					8.00		24.00																								20.00																		8.00					8.00							
H3916	002	0	1	04	01	H3916_002_0	5	4	Specialty Tier	1	4	010010	1	1	110100000010001000000101	34		90							1			90							34		34		34	14					718.73	33		33																							33																	33				33			33			
H3916	005	0	1	04	01	H3916_005_0	6	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	34		90							1			90							34				34	14		42.00		126.00																								105.00																		42.00								42.00				
H3916	005	0	1	04	01	H3916_005_0	6	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	34		90							1			90							34				34	14		90.00		270.00																								225.00																		90.00								90.00				
H3916	005	0	1	04	01	H3916_005_0	6	4	Specialty Tier	1	4	010010	1	1	110100000010001000000101	34		90							1			90							34		34		34	14					744.67	33		33																							33																	33				33			33			
H3916	005	0	1	04	01	H3916_005_0	6	1	Generic	3	4	010000	1	2	010100000010001000000100	34		90							1			90							34		34					8.00		24.00																								20.00																		8.00					8.00					1		
H3916	005	0	1	04	01	H3916_005_0	6	1	Generic	1	4	010000	1	2	010100000010001000000100	34		90							1			90							34		34					8.00		24.00																								20.00																		8.00					8.00							
H3916	015	0	1	04	01	H3916_015_0	5	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	34		90							1			90							34				34	14		90.00		270.00																								225.00																		90.00								90.00				
H3916	015	0	1	04	01	H3916_015_0	5	4	Specialty Tier	1	4	010010	1	1	110100000010001000000101	34		90							1			90							34		34		34	14					690.72	33		33																							33																	33				33			33			
H3916	015	0	1	04	01	H3916_015_0	5	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	34		90							1			90							34				34	14		45.00		135.00																								112.50																		45.00								45.00				
H3916	015	0	1	04	01	H3916_015_0	5	1	Generic	1	4	010000	1	2	010100000010001000000100	34		90							1			90							34		34					8.00		24.00																								20.00																		8.00					8.00							
H3916	018	0	1	04	01	H3916_018_0	5	1	Generic	1	4	010000	1	2	010100000010001000000100	34		90							1			90							34		34					10.00		30.00																								25.00																		10.00					10.00							
H3916	018	0	1	04	01	H3916_018_0	5	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	34		90							1			90							34				34	14		45.00		135.00																								112.50																		45.00								45.00				
H3916	018	0	1	04	01	H3916_018_0	5	4	Specialty Tier	1	4	010010	1	1	110100000010001000000101	34		90							1			90							34		34		34	14					640.99	33		33																							33																	33				33			33			
H3916	018	0	1	04	01	H3916_018_0	5	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	34		90							1			90							34				34	14		95.00		285.00																								237.50																		95.00								95.00				
H3916	019	0	1	04	01	H3916_019_0	8	4	Specialty Tier	1	4	010010	1	1	110100000010001000000101	34		90							1			90							34		34		34	14					798.75	33		33																							33																	33				33			33			
H3916	019	0	1	04	01	H3916_019_0	8	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	34		90							1			90							34				34	14		95.00		285.00																								237.50																		95.00								95.00				
H3916	019	0	1	04	01	H3916_019_0	8	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	34		90							1			90							34				34	14		45.00		135.00																								112.50																		45.00								45.00				
H3916	019	0	1	04	01	H3916_019_0	8	1	Generic	1	4	010000	1	2	010100000010001000000100	34		90							1			90							34		34					10.00		30.00																								25.00																		10.00					10.00							
H3916	020	0	1	04	01	H3916_020_0	8	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	34		90							1			90							34				34	14		95.00		285.00																								237.50																		95.00								95.00				
H3916	020	0	1	04	01	H3916_020_0	8	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	34		90							1			90							34				34	14		45.00		135.00																								112.50																		45.00								45.00				
H3916	020	0	1	04	01	H3916_020_0	8	1	Generic	1	4	010000	1	2	010100000010001000000100	34		90							1			90							34		34					10.00		30.00																								25.00																		10.00					10.00							
H3916	020	0	1	04	01	H3916_020_0	8	4	Specialty Tier	1	4	010010	1	1	110100000010001000000101	34		90							1			90							34		34		34	14					792.84	33		33																							33																	33				33			33			
H3916	022	0	1	04	01	H3916_022_0	5	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	34		90							1			90							34				34	14		45.00		135.00																								112.50																		45.00								45.00				
H3916	022	0	1	04	01	H3916_022_0	5	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	34		90							1			90							34				34	14		90.00		270.00																								225.00																		90.00								90.00				
H3916	022	0	1	04	01	H3916_022_0	5	1	Generic	1	4	010000	1	2	010100000010001000000100	34		90							1			90							34		34					9.00		27.00																								22.50																		9.00					9.00							
H3916	022	0	1	04	01	H3916_022_0	5	4	Specialty Tier	1	4	010010	1	1	110100000010001000000101	34		90							1			90							34		34		34	14					612.70	33		33																							33																	33				33			33			
H3916	024	0	1	04	01	H3916_024_0	5	1	Generic	1	4	010000	1	2	010100000010001000000100	34		90							1			90							34		34					9.00		27.00																								22.50																		9.00					9.00							
H3916	024	0	1	04	01	H3916_024_0	5	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	34		90							1			90							34				34	14		45.00		135.00																								112.50																		45.00								45.00				
H3916	024	0	1	04	01	H3916_024_0	5	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	34		90							1			90							34				34	14		90.00		270.00																								225.00																		90.00								90.00				
H3916	024	0	1	04	01	H3916_024_0	5	4	Specialty Tier	1	4	010010	1	1	110100000010001000000101	34		90							1			90							34		34		34	14					686.24	33		33																							33																	33				33			33			
H3916	025	0	1	04	01	H3916_025_0	6	4	Specialty Tier	1	4	010010	1	1	110100000010001000000101	34		90							1			90							34		34		34	14					687.25	33		33																							33																	33				33			33			
H3916	025	0	1	04	01	H3916_025_0	6	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	34		90							1			90							34				34	14		95.00		285.00																								237.50																		95.00								95.00				
H3916	025	0	1	04	01	H3916_025_0	6	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	34		90							1			90							34				34	14		45.00		135.00																								112.50																		45.00								45.00				
H3916	025	0	1	04	01	H3916_025_0	6	1	Generic	1	4	010000	1	2	010100000010001000000100	34		90							1			90							34		34					10.00		30.00																								25.00																		10.00					10.00							
H3920	001	0	1	01	01	H3920_001_0	8	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H3920	001	0	1	01	01	H3920_001_0	8	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					511.00	33		33																														33							33			33				33			33			
H3920	001	0	1	01	01	H3920_001_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					4.00		12.00																															8.00							12.00				4.00					4.00							
H3920	001	0	1	01	01	H3920_001_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					7.00		21.00																															14.00							21.00				7.00					7.00							
H3920	001	0	1	01	01	H3920_001_0	8	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H3921	001	0	1	04	01	H3921_001_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H3921	001	0	1	04	01	H3921_001_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H3921	001	0	1	04	01	H3921_001_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					486.00	33		33																														33							33			33				33			33			
H3921	001	0	1	04	01	H3921_001_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H3921	001	0	1	04	01	H3921_001_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H3921	008	0	1	04	01	H3921_008_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					415.00	33		33																														33							33			33				33			33			
H3921	008	0	1	04	01	H3921_008_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H3921	008	0	1	04	01	H3921_008_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H3921	008	0	1	04	01	H3921_008_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H3921	008	0	1	04	01	H3921_008_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H3923	013	0	1	04	01	H3923_013_0	10	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		44.00		132.00																						44.00		132.00																		44.00								44.00				
H3923	013	0	1	04	01	H3923_013_0	10	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		90.00		270.00																						90.00		270.00																		90.00								90.00				
H3923	013	0	1	04	01	H3923_013_0	10	5	Specialty Tier	1	4	010010	1	1	110000000010100000000111	31										31									31		31	14	31	14					388.00	33																							33																			33				33			33			
H3923	013	0	1	04	01	H3923_013_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000110	31		90							1	31		90							31		31	14				20.00		60.00																						20.00		60.00																		20.00					20.00							
H3923	013	0	1	04	01	H3923_013_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010101000000110	31		90							1	31		90							31		31	14				5.00		15.00																						5.00		15.00																		5.00					5.00							
H3923	017	0	1	04	01	H3923_017_0	9	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000110	31		90							1	31		90							31		31	14				15.00		45.00																						15.00		45.00																		15.00					15.00					1		
H3923	017	0	1	04	01	H3923_017_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010100000000111	31										31									31		31	14	31	14					436.00	33																							33																			33				33			33			
H3923	017	0	1	04	01	H3923_017_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		90.00		270.00																						90.00		270.00																		90.00								90.00				
H3923	017	0	1	04	01	H3923_017_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		44.00		132.00																						44.00		132.00																		44.00								44.00				
H3923	017	0	1	04	01	H3923_017_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000110	31		90							1	31		90							31		31	14				15.00		45.00																						15.00		45.00																		15.00					15.00							
H3923	017	0	1	04	01	H3923_017_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010101000000110	31		90							1	31		90							31		31	14				5.00		15.00																						5.00		15.00																		5.00					5.00							
H3923	017	0	1	04	01	H3923_017_0	9	1	Preferred Generic	3	4	001000	1	2	010100000010101000000110	31		90							1	31		90							31		31	14				5.00		15.00																						5.00		15.00																		5.00					5.00					1		
H3924	003	0	1	04	01	H3924_003_0	6	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	34		90							2			90							34		34					3.00		9.00																								9.00																		3.00					3.00					1		
H3924	003	0	1	04	01	H3924_003_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	34																			34		34		34	14					734.87	33																																										33				33			33			
H3924	003	0	1	04	01	H3924_003_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010001000000101	34		90							2			90							34		34		34	14		69.00		207.00																								207.00																		69.00					69.00			69.00				
H3924	003	0	1	04	01	H3924_003_0	6	3	Preferred Brand	1	4	010001	1	2	110100000010001000000101	34		90							2			90							34		34		34	14		39.00		117.00																								117.00																		39.00					39.00			39.00				
H3924	003	0	1	04	01	H3924_003_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	34		90							2			90							34		34					7.00		21.00																								21.00																		7.00					7.00							
H3924	003	0	1	04	01	H3924_003_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	34		90							2			90							34		34					3.00		9.00																								9.00																		3.00					3.00							
H3924	023	0	1	04	01	H3924_023_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	34																			34		34		34	14					734.87	33																																										33				33			33			
H3924	023	0	1	04	01	H3924_023_0	6	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	34		90							2			90							34		34					3.00		9.00																								9.00																		3.00					3.00					1		
H3924	023	0	1	04	01	H3924_023_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010001000000101	34		90							2			90							34		34		34	14		69.00		207.00																								207.00																		69.00					69.00			69.00				
H3924	023	0	1	04	01	H3924_023_0	6	3	Preferred Brand	1	4	010001	1	2	110100000010001000000101	34		90							2			90							34		34		34	14		39.00		117.00																								117.00																		39.00					39.00			39.00				
H3924	023	0	1	04	01	H3924_023_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	34		90							2			90							34		34					7.00		21.00																								21.00																		7.00					7.00							
H3924	023	0	1	04	01	H3924_023_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	34		90							2			90							34		34					3.00		9.00																								9.00																		3.00					3.00							
H3924	046	0	1	04	01	H3924_046_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	34		90							2			90							34		34					7.00		21.00																								21.00																		7.00					7.00							
H3924	046	0	1	04	01	H3924_046_0	6	3	Preferred Brand	1	4	010001	1	2	110100000010001000000101	34		90							2			90							34		34		34	14		39.00		117.00																								117.00																		39.00					39.00			39.00				
H3924	046	0	1	04	01	H3924_046_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010001000000101	34		90							2			90							34		34		34	14		69.00		207.00																								207.00																		69.00					69.00			69.00				
H3924	046	0	1	04	01	H3924_046_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	34																			34		34		34	14					734.87	33																																										33				33			33			
H3924	046	0	1	04	01	H3924_046_0	6	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	34		90							2			90							34		34					3.00		9.00																								9.00																		3.00					3.00					1		
H3924	046	0	1	04	01	H3924_046_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	34		90							2			90							34		34					3.00		9.00																								9.00																		3.00					3.00							
H3924	048	0	1	04	01	H3924_048_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	34		90							2			90							34		34					3.00		9.00																								9.00																		3.00					3.00							
H3924	048	0	1	04	01	H3924_048_0	6	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	34		90							2			90							34		34					3.00		9.00																								9.00																		3.00					3.00					1		
H3924	048	0	1	04	01	H3924_048_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	34																			34		34		34	14					734.87	33																																										33				33			33			
H3924	048	0	1	04	01	H3924_048_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010001000000101	34		90							2			90							34		34		34	14		69.00		207.00																								207.00																		69.00					69.00			69.00				
H3924	048	0	1	04	01	H3924_048_0	6	3	Preferred Brand	1	4	010001	1	2	110100000010001000000101	34		90							2			90							34		34		34	14		39.00		117.00																								117.00																		39.00					39.00			39.00				
H3924	048	0	1	04	01	H3924_048_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	34		90							2			90							34		34					7.00		21.00																								21.00																		7.00					7.00							
H3924	052	0	1	04	01	H3924_052_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	34		90							2			90							34		34					3.00		9.00																								9.00																		3.00					3.00							
H3924	052	0	1	04	01	H3924_052_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	34		90							2			90							34		34					7.00		21.00																								21.00																		7.00					7.00							
H3924	052	0	1	04	01	H3924_052_0	6	3	Preferred Brand	1	4	010001	1	2	110100000010001000000101	34		90							2			90							34		34		34	14		39.00		117.00																								117.00																		39.00					39.00			39.00				
H3924	052	0	1	04	01	H3924_052_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010001000000101	34		90							2			90							34		34		34	14		69.00		207.00																								207.00																		69.00					69.00			69.00				
H3924	052	0	1	04	01	H3924_052_0	6	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	34		90							2			90							34		34					3.00		9.00																								9.00																		3.00					3.00					1		
H3924	052	0	1	04	01	H3924_052_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	34																			34		34		34	14					734.87	33																																										33				33			33			
H3924	054	0	1	04	01	H3924_054_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010001000000101	34		90							2			90							34		34		34	14		69.00		207.00																								207.00																		69.00					69.00			69.00				
H3924	054	0	1	04	01	H3924_054_0	5	3	Preferred Brand	1	4	010001	1	2	110100000010001000000101	34		90							2			90							34		34		34	14		39.00		117.00																								117.00																		39.00					39.00			39.00				
H3924	054	0	1	04	01	H3924_054_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	34		90							2			90							34		34					7.00		21.00																								21.00																		7.00					7.00							
H3924	054	0	1	04	01	H3924_054_0	5	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	34		90							2			90							34		34					3.00		9.00																								9.00																		3.00					3.00							
H3924	054	0	1	04	01	H3924_054_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	34																			34		34		34	14					734.87	33																																										33				33			33			
H3924	054	0	1	04	01	H3924_054_0	5	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	34		90							2			90							34		34					3.00		9.00																								9.00																		3.00					3.00					1		
H3931	004	0	1	01	01	H3931_004_0	7	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					194.17	33	33	33																												33	33	33					33	33	33				33			33			33			
H3931	004	0	1	01	01	H3931_004_0	7	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H3931	004	0	1	01	01	H3931_004_0	7	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H3931	004	0	1	01	01	H3931_004_0	7	1	Preferred Generic	3	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					6.00	12.00	18.00																													6.00	12.00	12.00					6.00	12.00	18.00					6.00				6.00					1		
H3931	004	0	1	01	01	H3931_004_0	7	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					6.00	12.00	18.00																													6.00	12.00	12.00					6.00	12.00	18.00					6.00				6.00							
H3931	004	0	1	01	01	H3931_004_0	7	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H3931	058	0	1	01	01	H3931_058_0	6	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H3931	058	0	1	01	01	H3931_058_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H3931	058	0	1	01	01	H3931_058_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H3931	058	0	1	01	01	H3931_058_0	6	1	Preferred Generic	3	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					6.00	12.00	18.00																													6.00	12.00	12.00					6.00	12.00	18.00					6.00				6.00					1		
H3931	058	0	1	01	01	H3931_058_0	6	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					354.90	33	33	33																												33	33	33					33	33	33				33			33			33			
H3931	058	0	1	01	01	H3931_058_0	6	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					6.00	12.00	18.00																													6.00	12.00	12.00					6.00	12.00	18.00					6.00				6.00							
H3931	064	0	1	01	01	H3931_064_0	6	3	Preferred Brand	1	3	000001		2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		40.00	80.00	120.00																													40.00	80.00	80.00					40.00	80.00	120.00					40.00							40.00				
H3931	064	0	1	01	01	H3931_064_0	6	2	Non-Preferred Generic	1	3	000100		2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					30.00	60.00	90.00																													30.00	60.00	60.00					30.00	60.00	90.00					30.00				30.00							
H3931	064	0	1	01	01	H3931_064_0	6	1	Preferred Generic	1	3	001000		2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					6.00	12.00	18.00																													6.00	12.00	12.00					6.00	12.00	18.00					6.00				6.00							
H3931	064	0	1	01	01	H3931_064_0	6	4	Non-Preferred Brand	1	3	100000		2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H3931	064	0	1	01	01	H3931_064_0	6	5	Specialty Tier	1	3	010010		1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					210.09	25	25	25																												25	25	25					25	25	25				25			25			25			
H3931	065	0	1	01	01	H3931_065_0	6	5	Specialty Tier	1	3	010010		1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					381.11	25	25	25																												25	25	25					25	25	25				25			25			25			
H3931	065	0	1	01	01	H3931_065_0	6	3	Preferred Brand	1	3	000001		2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		37.00	74.00	111.00																													37.00	74.00	74.00					37.00	74.00	111.00					37.00							37.00				
H3931	065	0	1	01	01	H3931_065_0	6	2	Non-Preferred Generic	1	3	000100		2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					30.00	60.00	90.00																													30.00	60.00	60.00					30.00	60.00	90.00					30.00				30.00							
H3931	065	0	1	01	01	H3931_065_0	6	1	Preferred Generic	1	3	001000		2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					5.00	10.00	15.00																													5.00	10.00	10.00					5.00	10.00	15.00					5.00				5.00							
H3931	065	0	1	01	01	H3931_065_0	6	4	Non-Preferred Brand	1	3	100000		2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		85.00	170.00	255.00																													85.00	170.00	170.00					85.00	170.00	255.00					85.00							85.00				
H3931	070	0	1	01	01	H3931_070_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H3931	070	0	1	01	01	H3931_070_0	6	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H3931	070	0	1	01	01	H3931_070_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H3931	070	0	1	01	01	H3931_070_0	6	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					6.00	12.00	18.00																													6.00	12.00	12.00					6.00	12.00	18.00					6.00				6.00							
H3931	070	0	1	01	01	H3931_070_0	6	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					262.11	33	33	33																												33	33	33					33	33	33				33			33			33			
H3949	002	0	1	01	01	H3949_002_0	8	1	Preferred Generic	1	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					4.00	8.00	12.00																								3.00																		4.00					4.00							
H3949	002	0	1	01	01	H3949_002_0	8	2	Non-Preferred Generic	1	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		10.00	20.00	30.00																								21.00																		10.00					10.00			10.00				
H3949	002	0	1	01	01	H3949_002_0	8	3	Preferred Brand	1	4	000001	1	2	111100000010001000000001	30	60	90							2			90							30				31	14		40.00	80.00	120.00																								110.00																		40.00								40.00				
H3949	002	0	1	01	01	H3949_002_0	8	4	Non-Preferred Brand	1	4	100100	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		80.00	160.00	240.00																								230.00																		80.00					80.00			80.00				
H3949	002	0	1	01	01	H3949_002_0	8	5	Specialty Tier	1	4	010010	1	1	111100000010001000000101	30	60	90							2			90							30		31		31	14					313.85	33	33	33																							33																	33				33			33			
H3949	013	0	1	01	01	H3949_013_0	8	5	Specialty Tier	1	4	010010	1	1	111100000010001000000101	30	60	90							2			90							30		31		31	14					325.56	33	33	33																							33																	33				33			33			
H3949	013	0	1	01	01	H3949_013_0	8	4	Non-Preferred Brand	1	4	100100	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		70.00	140.00	210.00																								200.00																		70.00					70.00			70.00				
H3949	013	0	1	01	01	H3949_013_0	8	3	Preferred Brand	1	4	000001	1	2	111100000010001000000001	30	60	90							2			90							30				31	14		35.00	70.00	105.00																								95.00																		35.00								35.00				
H3949	013	0	1	01	01	H3949_013_0	8	1	Preferred Generic	1	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					0.00	0.00	0.00																								0.00																		0.00					0.00							
H3949	013	0	1	01	01	H3949_013_0	8	2	Non-Preferred Generic	1	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		0.00	0.00	0.00																								0.00																		0.00					0.00			0.00				
H3949	024	0	1	01	01	H3949_024_0	8	6	Select Diabetic Drugs	1	4	010010	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		5.00	10.00	15.00																								5.00																		5.00					5.00			5.00				
H3949	024	0	1	01	01	H3949_024_0	8	4	Non-Preferred Brand	1	4	100100	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		80.00	160.00	240.00																								230.00																		80.00					80.00			80.00				
H3949	024	0	1	01	01	H3949_024_0	8	3	Preferred Brand	1	4	000001	1	2	111100000010001000000001	30	60	90							2			90							30				31	14		40.00	80.00	120.00																								110.00																		40.00								40.00				
H3949	024	0	1	01	01	H3949_024_0	8	2	Non-Preferred Generic	1	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		10.00	20.00	30.00																								21.00																		10.00					10.00			10.00				
H3949	024	0	1	01	01	H3949_024_0	8	1	Preferred Generic	1	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					4.00	8.00	12.00																								3.00																		4.00					4.00							
H3949	024	0	1	01	01	H3949_024_0	8	5	Specialty Tier	1	4	010010	1	1	111100000010001000000101	30	60	90							2			90							30		31		31	14					284.07	33	33	33																							33																	33				33			33			
H3952	020	0	1	01	01	H3952_020_0	6	4	Specialty Tier	1	4	100000	1	1	110100000010001000000001	30		90							1			90							30				31	14					250.84	25		25																							25																	25							25			
H3952	020	0	1	01	01	H3952_020_0	6	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		80.00		240.00																								160.00																		80.00								80.00				
H3952	020	0	1	01	01	H3952_020_0	6	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		40.00		120.00																								80.00																		40.00								40.00				
H3952	020	0	1	01	01	H3952_020_0	6	1	Generic	1	4	010000	1	2	010100000010001000000110	30		90							1			90							30		31	14				5.00		15.00																								10.00																		5.00					5.00							
H3952	020	0	1	01	01	H3952_020_0	6	1	Generic	3	4	010000	1	2	010100000010001000000110	30		90							1			90							30		31	14				5.00		15.00																								10.00																		5.00					5.00					1		
H3952	045	0	1	01	01	H3952_045_0	6	4	Specialty Tier	1	4	100000	1	1	110100000010001000000001	30		90							1			90							30				31	14					457.31	25		25																							25																	25							25			
H3952	045	0	1	01	01	H3952_045_0	6	1	Generic	3	4	010000	1	2	010100000010001000000110	30		90							1			90							30		31	14				5.00		15.00																								10.00																		5.00					5.00					1		
H3952	045	0	1	01	01	H3952_045_0	6	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		80.00		240.00																								160.00																		80.00								80.00				
H3952	045	0	1	01	01	H3952_045_0	6	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		40.00		120.00																								80.00																		40.00								40.00				
H3952	045	0	1	01	01	H3952_045_0	6	1	Generic	1	4	010000	1	2	010100000010001000000110	30		90							1			90							30		31	14				5.00		15.00																								10.00																		5.00					5.00							
H3952	049	0	1	01	01	H3952_049_0	7	1	Generic	1	4	010000	1	2	010100000010001000000110	30		90							1			90							30		31	14				4.00		12.00																								8.00																		4.00					4.00							
H3952	049	0	1	01	01	H3952_049_0	7	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		40.00		120.00																								80.00																		40.00								40.00				
H3952	049	0	1	01	01	H3952_049_0	7	4	Specialty Tier	1	4	100000	1	1	110100000010001000000001	30		90							1			90							30				31	14					212.09	25		25																							25																	25							25			
H3952	049	0	1	01	01	H3952_049_0	7	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		80.00		240.00																								160.00																		80.00								80.00				
H3952	051	0	1	01	01	H3952_051_0	6	4	Specialty Tier	1	4	100000	1	1	110100000010001000000001	30		90							1			90							30				31	14					287.36	25		25																							25																	25							25			
H3952	051	0	1	01	01	H3952_051_0	6	1	Generic	1	4	010000	1	2	010100000010001000000110	30		90							1			90							30		31	14				4.00		12.00																								8.00																		4.00					4.00							
H3952	051	0	1	01	01	H3952_051_0	6	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		40.00		120.00																								80.00																		40.00								40.00				
H3952	051	0	1	01	01	H3952_051_0	6	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		80.00		240.00																								160.00																		80.00								80.00				
H3954	021	0	1	01	01	H3954_021_0	6	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	34		90							2			90							34		34					3.00		9.00																								9.00																		3.00					3.00					1		
H3954	021	0	1	01	01	H3954_021_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	34																			34		34		34	14					734.87	33																																										33				33			33			
H3954	021	0	1	01	01	H3954_021_0	6	3	Preferred Brand	1	4	010001	1	2	110100000010001000000101	34		90							2			90							34		34		34	14		39.00		117.00																								117.00																		39.00					39.00			39.00				
H3954	021	0	1	01	01	H3954_021_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	34		90							2			90							34		34					7.00		21.00																								21.00																		7.00					7.00							
H3954	021	0	1	01	01	H3954_021_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	34		90							2			90							34		34					3.00		9.00																								9.00																		3.00					3.00							
H3954	021	0	1	01	01	H3954_021_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010001000000101	34		90							2			90							34		34		34	14		69.00		207.00																								207.00																		69.00					69.00			69.00				
H3954	027	0	1	01	01	H3954_027_0	6	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	34		90							2			90							34		34					3.00		9.00																								9.00																		3.00					3.00					1		
H3954	027	0	1	01	01	H3954_027_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	34																			34		34		34	14					734.87	33																																										33				33			33			
H3954	027	0	1	01	01	H3954_027_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010001000000101	34		90							2			90							34		34		34	14		69.00		207.00																								207.00																		69.00					69.00			69.00				
H3954	027	0	1	01	01	H3954_027_0	6	3	Preferred Brand	1	4	010001	1	2	110100000010001000000101	34		90							2			90							34		34		34	14		39.00		117.00																								117.00																		39.00					39.00			39.00				
H3954	027	0	1	01	01	H3954_027_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	34		90							2			90							34		34					7.00		21.00																								21.00																		7.00					7.00							
H3954	027	0	1	01	01	H3954_027_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	34		90							2			90							34		34					3.00		9.00																								9.00																		3.00					3.00							
H3954	033	0	1	01	01	H3954_033_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	34		90							2			90							34		34					3.00		9.00																								9.00																		3.00					3.00							
H3954	033	0	1	01	01	H3954_033_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	34		90							2			90							34		34					7.00		21.00																								21.00																		7.00					7.00							
H3954	033	0	1	01	01	H3954_033_0	6	3	Preferred Brand	1	4	010001	1	2	110100000010001000000101	34		90							2			90							34		34		34	14		39.00		117.00																								117.00																		39.00					39.00			39.00				
H3954	033	0	1	01	01	H3954_033_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010001000000101	34		90							2			90							34		34		34	14		69.00		207.00																								207.00																		69.00					69.00			69.00				
H3954	033	0	1	01	01	H3954_033_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	34																			34		34		34	14					734.87	33																																										33				33			33			
H3954	033	0	1	01	01	H3954_033_0	6	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	34		90							2			90							34		34					3.00		9.00																								9.00																		3.00					3.00					1		
H3954	100	0	1	01	01	H3954_100_0	5	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	34		90							2			90							34		34					3.00		9.00																								9.00																		3.00					3.00							
H3954	100	0	1	01	01	H3954_100_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	34		90							2			90							34		34					7.00		21.00																								21.00																		7.00					7.00							
H3954	100	0	1	01	01	H3954_100_0	5	3	Preferred Brand	1	4	010001	1	2	110100000010001000000101	34		90							2			90							34		34		34	14		39.00		117.00																								117.00																		39.00					39.00			39.00				
H3954	100	0	1	01	01	H3954_100_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010001000000101	34		90							2			90							34		34		34	14		69.00		207.00																								207.00																		69.00					69.00			69.00				
H3954	100	0	1	01	01	H3954_100_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	34																			34		34		34	14					734.87	33																																										33				33			33			
H3954	100	0	1	01	01	H3954_100_0	5	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	34		90							2			90							34		34					3.00		9.00																								9.00																		3.00					3.00					1		
H3954	134	0	1	01	01	H3954_134_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	34		90							2			90							34		34					3.00		9.00																								9.00																		3.00					3.00							
H3954	134	0	1	01	01	H3954_134_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	34		90							2			90							34		34					7.00		21.00																								21.00																		7.00					7.00							
H3954	134	0	1	01	01	H3954_134_0	8	3	Preferred Brand	1	4	010001	1	2	110100000010001000000101	34		90							2			90							34		34		34	14		39.00		117.00																								117.00																		39.00					39.00			39.00				
H3954	134	0	1	01	01	H3954_134_0	8	4	Non-Preferred Brand	1	4	110000	1	2	110100000010001000000101	34		90							2			90							34		34		34	14		69.00		207.00																								207.00																		69.00					69.00			69.00				
H3954	134	0	1	01	01	H3954_134_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	34																			34		34		34	14					734.87	33																																										33				33			33			
H3954	134	0	1	01	01	H3954_134_0	8	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	34		90							2			90							34		34					3.00		9.00																								9.00																		3.00					3.00					1		
H3954	135	0	1	01	01	H3954_135_0	8	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	34		90							2			90							34		34					3.00		9.00																								9.00																		3.00					3.00					1		
H3954	135	0	1	01	01	H3954_135_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	34		90							2			90							34		34					3.00		9.00																								9.00																		3.00					3.00							
H3954	135	0	1	01	01	H3954_135_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	34		90							2			90							34		34					7.00		21.00																								21.00																		7.00					7.00							
H3954	135	0	1	01	01	H3954_135_0	8	3	Preferred Brand	1	4	010001	1	2	110100000010001000000101	34		90							2			90							34		34		34	14		39.00		117.00																								117.00																		39.00					39.00			39.00				
H3954	135	0	1	01	01	H3954_135_0	8	4	Non-Preferred Brand	1	4	110000	1	2	110100000010001000000101	34		90							2			90							34		34		34	14		69.00		207.00																								207.00																		69.00					69.00			69.00				
H3954	135	0	1	01	01	H3954_135_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	34																			34		34		34	14					734.87	33																																										33				33			33			
H3954	137	0	1	01	01	H3954_137_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	34																			34		34		34	14					734.87	33																																										33				33			33			
H3954	137	0	1	01	01	H3954_137_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010001000000101	34		90							2			90							34		34		34	14		69.00		207.00																								207.00																		69.00					69.00			69.00				
H3954	137	0	1	01	01	H3954_137_0	6	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	34		90							2			90							34		34					3.00		9.00																								9.00																		3.00					3.00					1		
H3954	137	0	1	01	01	H3954_137_0	6	3	Preferred Brand	1	4	010001	1	2	110100000010001000000101	34		90							2			90							34		34		34	14		39.00		117.00																								117.00																		39.00					39.00			39.00				
H3954	137	0	1	01	01	H3954_137_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	34		90							2			90							34		34					7.00		21.00																								21.00																		7.00					7.00							
H3954	137	0	1	01	01	H3954_137_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	34		90							2			90							34		34					3.00		9.00																								9.00																		3.00					3.00							
H3954	139	0	1	01	01	H3954_139_0	5	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	34		90							2			90							34		34					3.00		9.00																								9.00																		3.00					3.00							
H3954	139	0	1	01	01	H3954_139_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	34		90							2			90							34		34					7.00		21.00																								21.00																		7.00					7.00							
H3954	139	0	1	01	01	H3954_139_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010001000000101	34		90							2			90							34		34		34	14		69.00		207.00																								207.00																		69.00					69.00			69.00				
H3954	139	0	1	01	01	H3954_139_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	34																			34		34		34	14					734.87	33																																										33				33			33			
H3954	139	0	1	01	01	H3954_139_0	5	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	34		90							2			90							34		34					3.00		9.00																								9.00																		3.00					3.00					1		
H3954	139	0	1	01	01	H3954_139_0	5	3	Preferred Brand	1	4	010001	1	2	110100000010001000000101	34		90							2			90							34		34		34	14		39.00		117.00																								117.00																		39.00					39.00			39.00				
H3954	141	0	1	02	01	H3954_141_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	34		90							2			90							34		34					3.00		9.00																								9.00																		3.00					3.00							
H3954	141	0	1	02	01	H3954_141_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	34		90							2			90							34		34					7.00		21.00																								21.00																		7.00					7.00							
H3954	141	0	1	02	01	H3954_141_0	6	3	Preferred Brand	1	4	010001	1	2	110100000010001000000101	34		90							2			90							34		34		34	14		39.00		117.00																								117.00																		39.00					39.00			39.00				
H3954	141	0	1	02	01	H3954_141_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010001000000101	34		90							2			90							34		34		34	14		69.00		207.00																								207.00																		69.00					69.00			69.00				
H3954	141	0	1	02	01	H3954_141_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	34																			34		34		34	14					734.87	33																																										33				33			33			
H3954	141	0	1	02	01	H3954_141_0	6	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	34		90							2			90							34		34					3.00		9.00																								9.00																		3.00					3.00					1		
H3954	143	0	1	02	01	H3954_143_0	5	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	34		90							2			90							34		34					3.00		9.00																								9.00																		3.00					3.00					1		
H3954	143	0	1	02	01	H3954_143_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	34																			34		34		34	14					734.87	33																																										33				33			33			
H3954	143	0	1	02	01	H3954_143_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010001000000101	34		90							2			90							34		34		34	14		69.00		207.00																								207.00																		69.00					69.00			69.00				
H3954	143	0	1	02	01	H3954_143_0	5	3	Preferred Brand	1	4	010001	1	2	110100000010001000000101	34		90							2			90							34		34		34	14		39.00		117.00																								117.00																		39.00					39.00			39.00				
H3954	143	0	1	02	01	H3954_143_0	5	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	34		90							2			90							34		34					3.00		9.00																								9.00																		3.00					3.00							
H3954	143	0	1	02	01	H3954_143_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	34		90							2			90							34		34					7.00		21.00																								21.00																		7.00					7.00							
H3954	146	0	1	01	01	H3954_146_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	34		90							2			90							34		34					3.00		9.00																								9.00																		3.00					3.00							
H3954	146	0	1	01	01	H3954_146_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	34		90							2			90							34		34					7.00		21.00																								21.00																		7.00					7.00							
H3954	146	0	1	01	01	H3954_146_0	6	3	Preferred Brand	1	4	010001	1	2	110100000010001000000101	34		90							2			90							34		34		34	14		39.00		117.00																								117.00																		39.00					39.00			39.00				
H3954	146	0	1	01	01	H3954_146_0	6	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	34		90							2			90							34		34					3.00		9.00																								9.00																		3.00					3.00					1		
H3954	146	0	1	01	01	H3954_146_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010001000000101	34		90							2			90							34		34		34	14		69.00		207.00																								207.00																		69.00					69.00			69.00				
H3954	146	0	1	01	01	H3954_146_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	34																			34		34		34	14					734.87	33																																										33				33			33			
H3954	148	0	1	01	01	H3954_148_0	8	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	34		90							2			90							34		34					3.00		9.00																								9.00																		3.00					3.00					1		
H3954	148	0	1	01	01	H3954_148_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	34																			34		34		34	14					734.87	33																																										33				33			33			
H3954	148	0	1	01	01	H3954_148_0	8	4	Non-Preferred Brand	1	4	110000	1	2	110100000010001000000101	34		90							2			90							34		34		34	14		69.00		207.00																								207.00																		69.00					69.00			69.00				
H3954	148	0	1	01	01	H3954_148_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	34		90							2			90							34		34					3.00		9.00																								9.00																		3.00					3.00							
H3954	148	0	1	01	01	H3954_148_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	34		90							2			90							34		34					7.00		21.00																								21.00																		7.00					7.00							
H3954	148	0	1	01	01	H3954_148_0	8	3	Preferred Brand	1	4	010001	1	2	110100000010001000000101	34		90							2			90							34		34		34	14		39.00		117.00																								117.00																		39.00					39.00			39.00				
H3954	151	0	1	02	01	H3954_151_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	34																			34		34		34	14					734.87	33																																										33				33			33			
H3954	151	0	1	02	01	H3954_151_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010001000000101	34		90							2			90							34		34		34	14		69.00		207.00																								207.00																		69.00					69.00			69.00				
H3954	151	0	1	02	01	H3954_151_0	6	3	Preferred Brand	1	4	010001	1	2	110100000010001000000101	34		90							2			90							34		34		34	14		39.00		117.00																								117.00																		39.00					39.00			39.00				
H3954	151	0	1	02	01	H3954_151_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	34		90							2			90							34		34					7.00		21.00																								21.00																		7.00					7.00							
H3954	151	0	1	02	01	H3954_151_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	34		90							2			90							34		34					3.00		9.00																								9.00																		3.00					3.00							
H3954	151	0	1	02	01	H3954_151_0	6	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	34		90							2			90							34		34					3.00		9.00																								9.00																		3.00					3.00					1		
H3954	153	0	1	02	01	H3954_153_0	6	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	34		90							2			90							34		34					3.00		9.00																								9.00																		3.00					3.00					1		
H3954	153	0	1	02	01	H3954_153_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	34																			34		34		34	14					734.87	33																																										33				33			33			
H3954	153	0	1	02	01	H3954_153_0	6	3	Preferred Brand	1	4	010001	1	2	110100000010001000000101	34		90							2			90							34		34		34	14		39.00		117.00																								117.00																		39.00					39.00			39.00				
H3954	153	0	1	02	01	H3954_153_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	34		90							2			90							34		34					7.00		21.00																								21.00																		7.00					7.00							
H3954	153	0	1	02	01	H3954_153_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	34		90							2			90							34		34					3.00		9.00																								9.00																		3.00					3.00							
H3954	153	0	1	02	01	H3954_153_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010001000000101	34		90							2			90							34		34		34	14		69.00		207.00																								207.00																		69.00					69.00			69.00				
H3954	155	0	1	02	01	H3954_155_0	6	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	34		90							2			90							34		34					3.00		9.00																								9.00																		3.00					3.00					1		
H3954	155	0	1	02	01	H3954_155_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	34																			34		34		34	14					734.87	33																																										33				33			33			
H3954	155	0	1	02	01	H3954_155_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010001000000101	34		90							2			90							34		34		34	14		69.00		207.00																								207.00																		69.00					69.00			69.00				
H3954	155	0	1	02	01	H3954_155_0	6	3	Preferred Brand	1	4	010001	1	2	110100000010001000000101	34		90							2			90							34		34		34	14		39.00		117.00																								117.00																		39.00					39.00			39.00				
H3954	155	0	1	02	01	H3954_155_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	34		90							2			90							34		34					7.00		21.00																								21.00																		7.00					7.00							
H3954	155	0	1	02	01	H3954_155_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	34		90							2			90							34		34					3.00		9.00																								9.00																		3.00					3.00							
H3957	003	0	1	01	01	H3957_003_0	7	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	34		90							1			90							34				34	14		45.00		135.00																								112.50																		45.00								45.00				
H3957	003	0	1	01	01	H3957_003_0	7	1	Generic	1	4	010000	1	2	010100000010001000000100	34		90							1			90							34		34					9.00		27.00																								22.50																		9.00					9.00							
H3957	003	0	1	01	01	H3957_003_0	7	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	34		90							1			90							34				34	14		90.00		270.00																								225.00																		90.00								90.00				
H3957	003	0	1	01	01	H3957_003_0	7	4	Specialty Tier	1	4	010010	1	1	110100000010001000000101	34		90							1			90							34		34		34	14					604.35	33		33																							33																	33				33			33			
H3957	006	0	1	01	01	H3957_006_0	7	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	34		90							1			90							34				34	14		45.00		135.00																								112.50																		45.00								45.00				
H3957	006	0	1	01	01	H3957_006_0	7	1	Generic	1	4	010000	1	2	010100000010001000000100	34		90							1			90							34		34					9.00		27.00																								22.50																		9.00					9.00							
H3957	006	0	1	01	01	H3957_006_0	7	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	34		90							1			90							34				34	14		90.00		270.00																								225.00																		90.00								90.00				
H3957	006	0	1	01	01	H3957_006_0	7	4	Specialty Tier	1	4	010010	1	1	110100000010001000000101	34		90							1			90							34		34		34	14					575.71	33		33																							33																	33				33			33			
H3957	020	0	1	01	01	H3957_020_0	7	1	Generic	1	4	010000	1	2	010100000010001000000100	34		90							1			90							34		34					8.00		24.00																								20.00																		8.00					8.00							
H3957	020	0	1	01	01	H3957_020_0	7	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	34		90							1			90							34				34	14		42.00		126.00																								105.00																		42.00								42.00				
H3957	020	0	1	01	01	H3957_020_0	7	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	34		90							1			90							34				34	14		90.00		270.00																								225.00																		90.00								90.00				
H3957	020	0	1	01	01	H3957_020_0	7	4	Specialty Tier	1	4	010010	1	1	110100000010001000000101	34		90							1			90							34		34		34	14					644.02	33		33																							33																	33				33			33			
H3957	020	0	1	01	01	H3957_020_0	7	1	Generic	3	4	010000	1	2	010100000010001000000100	34		90							1			90							34		34					8.00		24.00																								20.00																		8.00					8.00					1		
H3957	021	0	1	01	01	H3957_021_0	7	1	Generic	1	4	010000	1	2	010100000010001000000100	34		90							1			90							34		34					8.00		24.00																								20.00																		8.00					8.00							
H3957	021	0	1	01	01	H3957_021_0	7	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	34		90							1			90							34				34	14		42.00		126.00																								105.00																		42.00								42.00				
H3957	021	0	1	01	01	H3957_021_0	7	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	34		90							1			90							34				34	14		90.00		270.00																								225.00																		90.00								90.00				
H3957	021	0	1	01	01	H3957_021_0	7	4	Specialty Tier	1	4	010010	1	1	110100000010001000000101	34		90							1			90							34		34		34	14					676.33	33		33																							33																	33				33			33			
H3957	021	0	1	01	01	H3957_021_0	7	1	Generic	3	4	010000	1	2	010100000010001000000100	34		90							1			90							34		34					8.00		24.00																								20.00																		8.00					8.00					1		
H3957	031	0	1	01	01	H3957_031_0	7	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	34		90							1			90							34				34	14		45.00		135.00																								112.50																		45.00								45.00				
H3957	031	0	1	01	01	H3957_031_0	7	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	34		90							1			90							34				34	14		95.00		285.00																								237.50																		95.00								95.00				
H3957	031	0	1	01	01	H3957_031_0	7	4	Specialty Tier	1	4	010010	1	1	110100000010001000000101	34		90							1			90							34		34		34	14					788.16	33		33																							33																	33				33			33			
H3957	031	0	1	01	01	H3957_031_0	7	1	Generic	1	4	010000	1	2	010100000010001000000100	34		90							1			90							34		34					10.00		30.00																								25.00																		10.00					10.00							
H3957	032	0	1	01	01	H3957_032_0	7	4	Specialty Tier	1	4	010010	1	1	110100000010001000000101	34		90							1			90							34		34		34	14					616.82	33		33																							33																	33				33			33			
H3957	032	0	1	01	01	H3957_032_0	7	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	34		90							1			90							34				34	14		95.00		285.00																								237.50																		95.00								95.00				
H3957	032	0	1	01	01	H3957_032_0	7	1	Generic	1	4	010000	1	2	010100000010001000000100	34		90							1			90							34		34					10.00		30.00																								25.00																		10.00					10.00							
H3957	032	0	1	01	01	H3957_032_0	7	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	34		90							1			90							34				34	14		45.00		135.00																								112.50																		45.00								45.00				
H3957	036	0	1	01	01	H3957_036_0	8	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	34		90							1			90							34				34	14		95.00		285.00																								237.50																		95.00								95.00				
H3957	036	0	1	01	01	H3957_036_0	8	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	34		90							1			90							34				34	14		45.00		135.00																								112.50																		45.00								45.00				
H3957	036	0	1	01	01	H3957_036_0	8	1	Generic	1	4	010000	1	2	010100000010001000000100	34		90							1			90							34		34					10.00		30.00																								25.00																		10.00					10.00							
H3957	036	0	1	01	01	H3957_036_0	8	4	Specialty Tier	1	4	010010	1	1	110100000010001000000101	34		90							1			90							34		34		34	14					899.02	33		33																							33																	33				33			33			
H3957	037	0	1	01	01	H3957_037_0	8	1	Generic	1	4	010000	1	2	010100000010001000000100	34		90							1			90							34		34					10.00		30.00																								25.00																		10.00					10.00							
H3957	037	0	1	01	01	H3957_037_0	8	4	Specialty Tier	1	4	010010	1	1	110100000010001000000101	34		90							1			90							34		34		34	14					1259.67	33		33																							33																	33				33			33			
H3957	037	0	1	01	01	H3957_037_0	8	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	34		90							1			90							34				34	14		45.00		135.00																								112.50																		45.00								45.00				
H3957	037	0	1	01	01	H3957_037_0	8	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	34		90							1			90							34				34	14		95.00		285.00																								237.50																		95.00								95.00				
H3959	001	0	1	01	01	H3959_001_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					5.00		15.00																						5.00		12.50																		5.00					5.00							
H3959	001	0	1	01	01	H3959_001_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					25.00		75.00																						25.00		62.50																		25.00					25.00							
H3959	001	0	1	01	01	H3959_001_0	8	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		35.00		105.00																						35.00		87.50																		35.00								35.00				
H3959	001	0	1	01	01	H3959_001_0	8	4	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		80.00		240.00																						80.00		240.00																		80.00					80.00			80.00				
H3959	001	0	1	01	01	H3959_001_0	8	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					5.00		15.00																						5.00		12.50																		5.00					5.00					1		
H3959	001	0	1	01	01	H3959_001_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					332.65	33																																										33				33			33			
H3959	002	0	1	01	01	H3959_002_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					322.52	33																																										33				33			33			
H3959	002	0	1	01	01	H3959_002_0	8	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					5.00		15.00																						5.00		12.50																		5.00					5.00					1		
H3959	002	0	1	01	01	H3959_002_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					25.00		75.00																						25.00		62.50																		25.00					25.00							
H3959	002	0	1	01	01	H3959_002_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					5.00		15.00																						5.00		12.50																		5.00					5.00							
H3959	002	0	1	01	01	H3959_002_0	8	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		35.00		105.00																						35.00		87.50																		35.00								35.00				
H3959	002	0	1	01	01	H3959_002_0	8	4	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		80.00		240.00																						80.00		240.00																		80.00					80.00			80.00				
H3959	010	0	1	01	01	H3959_010_0	6	4	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		81.00		243.00																						81.00		243.00																		81.00					81.00			81.00				
H3959	010	0	1	01	01	H3959_010_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					337.66	33																																										33				33			33			
H3959	010	0	1	01	01	H3959_010_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		35.00		105.00																						35.00		87.50																		35.00								35.00				
H3959	010	0	1	01	01	H3959_010_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					24.00		72.00																						24.00		60.00																		24.00					24.00							
H3959	010	0	1	01	01	H3959_010_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					5.00		15.00																						5.00		12.50																		5.00					5.00							
H3959	011	0	1	01	01	H3959_011_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					502.63	33																																										33				33			33			
H3959	011	0	1	01	01	H3959_011_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					24.00		72.00																						24.00		60.00																		24.00					24.00							
H3959	011	0	1	01	01	H3959_011_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		35.00		105.00																						35.00		87.50																		35.00								35.00				
H3959	011	0	1	01	01	H3959_011_0	6	4	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		85.00		255.00																						85.00		255.00																		85.00					85.00			85.00				
H3959	011	0	1	01	01	H3959_011_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					6.00		18.00																						6.00		15.00																		6.00					6.00							
H3959	031	0	1	01	01	H3959_031_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					405.21	33																																										33				33			33			
H3959	031	0	1	01	01	H3959_031_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					4.00		12.00																						4.00		10.00																		4.00					4.00							
H3959	031	0	1	01	01	H3959_031_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					25.00		75.00																						25.00		62.50																		25.00					25.00							
H3959	031	0	1	01	01	H3959_031_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		35.00		105.00																						35.00		87.50																		35.00								35.00				
H3959	031	0	1	01	01	H3959_031_0	6	4	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		85.00		255.00																						85.00		255.00																		85.00					85.00			85.00				
H3959	032	0	1	01	01	H3959_032_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					330.66	33																																										33				33			33			
H3959	032	0	1	01	01	H3959_032_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		87.00		261.00																						87.00		261.00																		87.00					87.00			87.00				
H3959	032	0	1	01	01	H3959_032_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		34.00		102.00																						34.00		85.00																		34.00								34.00				
H3959	032	0	1	01	01	H3959_032_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					4.00		12.00																						4.00		10.00																		4.00					4.00							
H3959	032	0	1	01	01	H3959_032_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					24.00		72.00																						24.00		60.00																		24.00					24.00							
H3959	033	0	1	01	01	H3959_033_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					405.19	33																																										33				33			33			
H3959	033	0	1	01	01	H3959_033_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					6.00		18.00																						6.00		15.00																		6.00					6.00							
H3959	033	0	1	01	01	H3959_033_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					25.00		75.00																						25.00		62.50																		25.00					25.00							
H3959	033	0	1	01	01	H3959_033_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		35.00		105.00																						35.00		87.50																		35.00								35.00				
H3959	033	0	1	01	01	H3959_033_0	6	4	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		85.00		255.00																						85.00		255.00																		85.00					85.00			85.00				
H3959	037	0	1	01	01	H3959_037_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					405.27	33																																										33				33			33			
H3959	037	0	1	01	01	H3959_037_0	6	4	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		75.00		225.00																						75.00		225.00																		75.00					75.00			75.00				
H3959	037	0	1	01	01	H3959_037_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		35.00		105.00																						35.00		87.50																		35.00								35.00				
H3959	037	0	1	01	01	H3959_037_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					25.00		75.00																						25.00		62.50																		25.00					25.00							
H3959	037	0	1	01	01	H3959_037_0	6	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					6.00		18.00																						6.00		15.00																		6.00					6.00					1		
H3959	037	0	1	01	01	H3959_037_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					6.00		18.00																						6.00		15.00																		6.00					6.00							
H3962	001	0	1	01	01	H3962_001_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010101000000110	31		90							1	31		90							31		31	14				4.00		12.00																						4.00		12.00																		4.00					4.00							
H3962	001	0	1	01	01	H3962_001_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000110	31		90							1	31		90							31		31	14				12.00		36.00																						12.00		36.00																		12.00					12.00							
H3962	001	0	1	01	01	H3962_001_0	8	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		38.00		114.00																						38.00		114.00																		38.00								38.00				
H3962	001	0	1	01	01	H3962_001_0	8	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		89.00		267.00																						89.00		267.00																		89.00								89.00				
H3962	001	0	1	01	01	H3962_001_0	8	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000110	31		90							1	31		90							31		31	14				12.00		36.00																						12.00		36.00																		12.00					12.00					1		
H3962	001	0	1	01	01	H3962_001_0	8	1	Preferred Generic	3	4	001000	1	2	010100000010101000000110	31		90							1	31		90							31		31	14				4.00		12.00																						4.00		12.00																		4.00					4.00					1		
H3962	001	0	1	01	01	H3962_001_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010100000000111	31										31									31		31	14	31	14					384.00	33																							33																			33				33			33			
H3962	004	0	1	01	01	H3962_004_0	10	5	Specialty Tier	1	4	010010	1	1	110000000010100000000111	31										31									31		31	14	31	14					474.00	33																							33																			33				33			33			
H3962	004	0	1	01	01	H3962_004_0	10	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		89.00		267.00																						89.00		267.00																		89.00								89.00				
H3962	004	0	1	01	01	H3962_004_0	10	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		38.00		114.00																						38.00		114.00																		38.00								38.00				
H3962	004	0	1	01	01	H3962_004_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010101000000110	31		90							1	31		90							31		31	14				5.00		15.00																						5.00		15.00																		5.00					5.00							
H3962	004	0	1	01	01	H3962_004_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000110	31		90							1	31		90							31		31	14				15.00		45.00																						15.00		45.00																		15.00					15.00							
H3962	007	0	1	01	01	H3962_007_0	9	4	Specialty Tier	1	4	010001	1	1	110000000010100000000111	31										31									31		31	14	31	14					189.00	33																							33																			33				33			33			
H3962	007	0	1	01	01	H3962_007_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010101000000110	31		90							1	31		90							31		31	14				5.00		15.00																						5.00		15.00																		5.00					5.00							
H3962	007	0	1	01	01	H3962_007_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000110	31		90							1	31		90							31		31	14				20.00		60.00																						20.00		60.00																		20.00					20.00							
H3962	007	0	1	01	01	H3962_007_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		38.00		114.00																						38.00		114.00																		38.00								38.00				
H3964	003	0	1	02	01	H3964_003_0	9	3	Preferred Brand	1	4	000001	1	2	111100000010001000000001	30	60	90							2			90							30				31	14		40.00	80.00	120.00																								110.00																		40.00								40.00				
H3964	003	0	1	02	01	H3964_003_0	9	1	Preferred Generic	1	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					7.00	14.00	21.00																								12.00																		7.00					7.00							
H3964	003	0	1	02	01	H3964_003_0	9	2	Non-Preferred Generic	1	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		10.00	20.00	30.00																								21.00																		10.00					10.00			10.00				
H3964	003	0	1	02	01	H3964_003_0	9	5	Specialty Tier	1	4	010010	1	1	111100000010001000000101	30	60	90							2			90							30		31		31	14					367.89	28	28	28																							28																	28				28			28			
H3964	003	0	1	02	01	H3964_003_0	9	4	Non-Preferred Brand	1	4	100100	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		80.00	160.00	240.00																								230.00																		80.00					80.00			80.00				
H4003	001	0	1	02	01	H4003_001_0	11	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		29.00		87.00																								58.00																		29.00								29.00				
H4003	001	0	1	02	01	H4003_001_0	11	1	Generic	1	4	010000	1	2	010100000010001000000110	30		90							2			90							30		31	14				5.00		15.00																								10.00																		5.00					5.00							
H4003	001	0	1	02	01	H4003_001_0	11	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							2			90							30				31	14		50.00		150.00																								100.00																		50.00								50.00				
H4003	001	0	1	02	01	H4003_001_0	11	4	Specialty Tier	1	4	001001	1	1	110100000010001000000111	30		90							2			90							30		31	14	31	14					120.00	25		25																							25																	25				25			25			
H4003	001	0	1	02	01	H4003_001_0	11	1	Generic	3	4	010000	1	2	010100000010001000000110	30		90							2			90							30		31	14				5.00		15.00																								10.00																		5.00					5.00					2		
H4003	009	0	1	01	01	H4003_009_0	10	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		20.00		60.00																								40.00																		20.00								20.00				
H4003	009	0	1	01	01	H4003_009_0	10	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							2			90							30				31	14		45.00		135.00																								90.00																		45.00								45.00				
H4003	009	0	1	01	01	H4003_009_0	10	5	Specialty Tier	1	4	001001	1	1	110100000010001000000111	30		90							2			90							30		31	14	31	14					120.00	25		25																							25																	25				25			25			
H4003	009	0	1	01	01	H4003_009_0	10	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							2			90							30		31	14				3.00		9.00																								6.00																		3.00					3.00					2		
H4003	009	0	1	01	01	H4003_009_0	10	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				5.00		15.00																								10.00																		5.00					5.00					2		
H4003	009	0	1	01	01	H4003_009_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				5.00		15.00																								10.00																		5.00					5.00							
H4003	009	0	1	01	01	H4003_009_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							2			90							30		31	14				3.00		9.00																								6.00																		3.00					3.00							
H4003	015	0	1	01	01	H4003_015_0	7	2	Brand	1	4	000010	1	2	110100000010001000000001	30		90							2			90							30				31	14		35.00		105.00																								70.00																		35.00								35.00				
H4003	015	0	1	01	01	H4003_015_0	7	1	Generic	1	4	010000	1	2	010100000010001000000110	30		90							2			90							30		31	14				5.00		15.00																								10.00																		5.00					5.00							
H4003	015	0	1	01	01	H4003_015_0	7	3	Specialty Tier	1	4	001001	1	1	110100000010001000000111	30		90							2			90							30		31	14	31	14					120.00	30		30																							30																	30				30			30			
H4003	019	0	1	01	01	H4003_019_0	7	1	Generic	1	4	010000	1	2	010100000010001000000110	30		90							2			90							30		31	14				4.00		12.00																								8.00																		4.00					4.00							
H4003	019	0	1	01	01	H4003_019_0	7	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		30.00		90.00																								60.00																		30.00								30.00				
H4003	019	0	1	01	01	H4003_019_0	7	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							2			90							30				31	14		60.00		180.00																								120.00																		60.00								60.00				
H4003	019	0	1	01	01	H4003_019_0	7	4	Specialty Tier	1	4	001001	1	1	110100000010001000000111	30		90							2			90							30		31	14	31	14					120.00	25		25																							25																	25				25			25			
H4003	019	0	1	01	01	H4003_019_0	7	1	Generic	3	4	010000	1	2	010100000010001000000110	30		90							2			90							30		31	14				4.00		12.00																								8.00																		4.00					4.00					2		
H4003	019	0	1	01	01	H4003_019_0	7	2	Preferred Brand	3	4	000001	1	1	110100000010001000000001	30		90							2			90							30				31	14					85.00	50		50																							50																	50							50	2		
H4003	025	0	1	02	01	H4003_025_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							2			90							30		31	14				2.00		6.00																								4.00																		2.00					2.00							
H4003	025	0	1	02	01	H4003_025_0	7	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				5.00		15.00																								10.00																		5.00					5.00					2		
H4003	025	0	1	02	01	H4003_025_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				5.00		15.00																								10.00																		5.00					5.00							
H4003	025	0	1	02	01	H4003_025_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		25.00		75.00																								50.00																		25.00								25.00				
H4003	025	0	1	02	01	H4003_025_0	7	4	Non-Preferred Brand	1	4	100000	3	2	110100000010001000000001	30		90							2			90							30				31	14		50.00		150.00																								100.00																		50.00								50.00				
H4003	025	0	1	02	01	H4003_025_0	7	5	Specialty Tier	1	4	001001	1	1	110100000010001000000111	30		90							2			90							30		31	14	31	14					120.00	30		30																							30																	30				30			30			
H4003	025	0	1	02	01	H4003_025_0	7	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							2			90							30		31	14				2.00		6.00																								4.00																		2.00					2.00					2		
H4004	015	0	1	02	01	H4004_015_0	8	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							2			90							30				31	14		50.00		150.00																								100.00																		50.00								50.00				
H4004	015	0	1	02	01	H4004_015_0	8	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		29.00		87.00																								58.00																		29.00								29.00				
H4004	015	0	1	02	01	H4004_015_0	8	4	Specialty Tier	1	4	001001	1	1	110100000010001000000111	30		90							2			90							30		31	14	31	14					120.00	25		25																							25																	25				25			25			
H4004	015	0	1	02	01	H4004_015_0	8	1	Generic	1	4	010000	1	2	010100000010001000000110	30		90							2			90							30		31	14				5.00		15.00																								10.00																		5.00					5.00							
H4004	015	0	1	02	01	H4004_015_0	8	1	Generic	3	4	010000	1	2	010100000010001000000110	30		90							2			90							30		31	14				5.00		15.00																								10.00																		5.00					5.00					2		
H4004	035	0	1	01	01	H4004_035_0	8	1	Generic	3	4	010000	1	2	010100000010001000000110	30		90							2			90							30		31	14				5.00		15.00																								10.00																		5.00					5.00					2		
H4004	035	0	1	01	01	H4004_035_0	8	3	Specialty Tier	1	4	001001	1	1	110100000010001000000111	30		90							2			90							30		31	14	31	14					120.00	25		25																							25																	25				25			25			
H4004	035	0	1	01	01	H4004_035_0	8	1	Generic	1	4	010000	1	2	010100000010001000000110	30		90							2			90							30		31	14				5.00		15.00																								10.00																		5.00					5.00							
H4004	035	0	1	01	01	H4004_035_0	8	2	Brand	1	4	000010	1	2	110100000010001000000001	30		90							2			90							30				31	14		29.00		87.00																								58.00																		29.00								29.00				
H4004	050	0	1	01	01	H4004_050_0	7	1	Generic	3	4	010000	1	2	010100000010001000000110	30		90							2			90							30		31	14				5.00		15.00																								10.00																		5.00					5.00					2		
H4004	050	0	1	01	01	H4004_050_0	7	3	Specialty Tier	1	4	001001	1	1	110100000010001000000111	30		90							2			90							30		31	14	31	14					120.00	25		25																							25																	25				25			25			
H4004	050	0	1	01	01	H4004_050_0	7	1	Generic	1	4	010000	1	2	010100000010001000000110	30		90							2			90							30		31	14				5.00		15.00																								10.00																		5.00					5.00							
H4004	050	0	1	01	01	H4004_050_0	7	2	Brand	1	4	000010	1	2	110100000010001000000001	30		90							2			90							30				31	14		25.00		75.00																								50.00																		25.00								25.00				
H4005	004	0	1	04	01	H4005_004_0	7	1	Generic	1	4	010010	1	2	110100000010001000000111	30		90							2			90							30		31	14	31	14		5.00		15.00																								15.00																		5.00					5.00			5.00				
H4005	004	0	1	04	01	H4005_004_0	7	2	Preferred Brand	1	4	010001	3	2	110100000010001000000111	30		90							2			90							30		31	14	31	14		25.00		75.00																								75.00																		25.00					25.00			25.00				
H4005	004	0	1	04	01	H4005_004_0	7	3	Non-Preferred Brand	1	4	110000	3	3	110100000010001000000111	30		90							2			90							30		31	14	31	14		35.00		105.00	40.42	25		25																				105.00			25															35.00		25			35.00	25		35.00	25			
H4005	004	0	1	04	01	H4005_004_0	7	4	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							2			90							30		31	14	31	14					647.25	25		25																							25																	25				25			25			
H4005	004	0	1	04	01	H4005_004_0	7	1	Generic	3	4	010010	1	2	110100000010001000000111	30		90							2			90							30		31	14	31	14		5.00		15.00																								15.00																		5.00					5.00			5.00		1		
H4006	007	0	1	01	01	H4006_007_0	7	4	Specialty Tier	1	4	110001	1	1	110000000010100000000101	30										30									30		31		31	1					809.48	33																							33																			33				33			33			
H4006	007	0	1	01	01	H4006_007_0	7	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							1	30		90							30				31	1		50.00		150.00																						50.00		100.00																		50.00								50.00				
H4006	007	0	1	01	01	H4006_007_0	7	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							1	30		90							30				31	1		25.00		75.00																						25.00		50.00																		25.00								25.00				
H4006	007	0	1	01	01	H4006_007_0	7	1	Generic	1	4	010000	1	2	010100000010101000000100	30		90							1	30		90							30		31					5.00		15.00																						5.00		10.00																		5.00					5.00							
H4006	007	0	1	01	01	H4006_007_0	7	1	Generic	3	4	010000	1	2	010100000010101000000100	30		90							1	30		90							30		31					5.00		15.00																						5.00		10.00																		5.00					5.00					1		
H4006	008	0	1	02	01	H4006_008_0	9	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		90							1	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00					1		
H4006	008	0	1	02	01	H4006_008_0	9	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000100	30		90							1	30		90							30		31					3.00		9.00																						3.00		6.00																		3.00					3.00					1		
H4006	008	0	1	02	01	H4006_008_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							1	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00							
H4006	008	0	1	02	01	H4006_008_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							1	30		90							30		31					3.00		9.00																						3.00		6.00																		3.00					3.00							
H4006	008	0	1	02	01	H4006_008_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							1	30		90							30				31	1		18.00		54.00																						18.00		36.00																		18.00								18.00				
H4006	008	0	1	02	01	H4006_008_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							1	30		90							30				31	1		36.00		108.00																						36.00		72.00																		36.00								36.00				
H4006	008	0	1	02	01	H4006_008_0	9	5	Specialty Tier	1	4	101101	1	1	110000000010100000000101	30										30									30		31		31	1					613.24	25																							25																			25				25			25			
H4007	005	0	1	01	01	H4007_005_0	7	2	Preferred Brand	1	3	000101		1	110100000010101000000101	30		90							2	30		90							30		31		31	14					36.00	25		25																					25		25																	25				25			25			
H4007	005	0	1	01	01	H4007_005_0	7	1	Preferred Generic	1	3	001010		1	110100000010101000000101	30		90							2	30		90							30		31		31	14					4.00	25		25																					25		25																	25				25			25			
H4007	005	0	1	01	01	H4007_005_0	7	3	Non-Preferred Brand	1	3	100100		1	110100000010101000000101	30		90							2	30		90							30		31		31	14					46.00	25		25																					25		25																	25				25			25			
H4007	012	0	1	01	01	H4007_012_0	8	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	1
H4007	012	0	1	01	01	H4007_012_0	8	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	1	
H4007	012	0	1	01	01	H4007_012_0	8	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H4007	012	0	1	01	01	H4007_012_0	8	2	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		25.00		75.00																													25.00		65.00					25.00		75.00				25.00					25.00			25.00				
H4007	012	0	1	01	01	H4007_012_0	8	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		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	8	2	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		25.00		75.00																													25.00		65.00					25.00		75.00				25.00					25.00			25.00		2	3	
H4007	014	0	1	01	01	H4007_014_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H4007	014	0	1	01	01	H4007_014_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					814.00	33																														33							33					33				33			33	2	3	
H4007	014	0	1	01	01	H4007_014_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	3	
H4007	014	0	1	01	01	H4007_014_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		20.00		60.00																													20.00		50.00					20.00		60.00				20.00					20.00			20.00		2	3	
H4007	014	0	1	01	01	H4007_014_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	2	
H4007	014	0	1	01	01	H4007_014_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	1
H4007	014	0	1	01	01	H4007_014_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					785.00	33																														33							33					33				33			33			
H4007	014	0	1	01	01	H4007_014_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		20.00		60.00																													20.00		50.00					20.00		60.00				20.00					20.00			20.00				
H4007	014	0	1	01	01	H4007_014_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H4007	014	0	1	01	01	H4007_014_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H4011	003	0	1	04	01	H4011_003_0	9	4	Specialty Tier	1	4	000010	1	1	110100000010000000000001	30		90							2										30				31	14					127.00	25		25																																								25							25			
H4011	003	0	1	04	01	H4011_003_0	9	2	Preferred Brand	1	4	000001	1	2	110100000010000000000001	30		90							2										30				31	14		25.00		75.00																																										25.00								25.00				
H4011	003	0	1	04	01	H4011_003_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010000000000110	30		90							2										30		31	14				5.00		15.00																																										5.00					5.00							
H4011	003	0	1	04	01	H4011_003_0	9	3	Non-Preferred Brand	1	4	100000	1	2	110100000010000000000001	30		90							2										30				31	14		45.00		135.00																																										45.00								45.00				
H4011	003	0	1	04	01	H4011_003_0	9	1	Preferred Generic	3	4	001000	1	2	010100000010000000000110	30		90							2										30		31	14				5.00		15.00																																										5.00					5.00					1		
H4012	008	0	1	01	01	H4012_008_0	7	1	Generic	3	4	010010	3	2	110100000010001000000111	30		90							2			90							30		31	14	31	14		5.00		15.00																								15.00																		5.00					5.00			5.00		1		
H4012	008	0	1	01	01	H4012_008_0	7	1	Generic	1	4	010010	3	2	110100000010001000000111	30		90							2			90							30		31	14	31	14		5.00		15.00																								15.00																		5.00					5.00			5.00				
H4012	008	0	1	01	01	H4012_008_0	7	4	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							2			90							30		31	14	31	14					680.71	25		25																							25																	25				25			25			
H4012	008	0	1	01	01	H4012_008_0	7	3	Non-Preferred Brand	1	4	110000	3	2	110100000010001000000111	30		90							2			90							30		31	14	31	14		45.00		135.00																								135.00																		45.00					45.00			45.00				
H4012	008	0	1	01	01	H4012_008_0	7	2	Preferred Brand	1	4	010001	3	2	110100000010001000000111	30		90							2			90							30		31	14	31	14		20.00		60.00																								60.00																		20.00					20.00			20.00				
H4036	004	0	1	04	01	H4036_004_0	11	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				4.00	8.00	12.00																						4.00	8.00	6.00																		4.00					4.00							
H4036	004	0	1	04	01	H4036_004_0	11	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					865.00	33																							33																			33				33			33			
H4036	004	0	1	04	01	H4036_004_0	11	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				10.00	20.00	30.00																						10.00	20.00	15.00																		10.00					10.00							
H4036	004	0	1	04	01	H4036_004_0	11	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00					45.00			45.00				
H4036	004	0	1	04	01	H4036_004_0	11	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H4036	004	0	1	04	01	H4036_004_0	11	5	Injectable Drugs	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					62.00	33	33	33																					33	33	33																	33				33			33			
H4036	005	0	1	04	01	H4036_005_0	11	1	Preferred Generic	1	3	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				4.00	8.00	12.00																						4.00	8.00	6.00																		4.00					4.00							
H4036	005	0	1	04	01	H4036_005_0	11	6	Specialty Tier	1	3	010010		1	110000000010100000000111	30										30									30		34	14	34	14					865.00	33																							33																			33				33			33			
H4036	005	0	1	04	01	H4036_005_0	11	5	Injectable Drugs	1	3	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					62.00	33	33	33																					33	33	33																	33				33			33			
H4036	005	0	1	04	01	H4036_005_0	11	4	Non-Preferred Brand	1	3	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H4036	005	0	1	04	01	H4036_005_0	11	3	Preferred Brand	1	3	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		42.00	84.00	126.00																						42.00	84.00	105.00																		42.00					42.00			42.00				
H4036	005	0	1	04	01	H4036_005_0	11	2	Non-Preferred Generic	1	3	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				8.00	16.00	24.00																						8.00	16.00	12.00																		8.00					8.00							
H4036	007	0	1	04	01	H4036_007_0	11	5	Injectable Drugs	1	3	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					62.00	33	33	33																					33	33	33																	33				33			33			
H4036	007	0	1	04	01	H4036_007_0	11	4	Non-Preferred Brand	1	3	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H4036	007	0	1	04	01	H4036_007_0	11	3	Preferred Brand	1	3	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		42.00	84.00	126.00																						42.00	84.00	105.00																		42.00					42.00			42.00				
H4036	007	0	1	04	01	H4036_007_0	11	2	Non-Preferred Generic	1	3	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				8.00	16.00	24.00																						8.00	16.00	12.00																		8.00					8.00							
H4036	007	0	1	04	01	H4036_007_0	11	1	Preferred Generic	1	3	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				4.00	8.00	12.00																						4.00	8.00	6.00																		4.00					4.00							
H4036	007	0	1	04	01	H4036_007_0	11	6	Specialty Tier	1	3	010010		1	110000000010100000000111	30										30									30		34	14	34	14					865.00	33																							33																			33				33			33			
H4102	001	0	1	02	01	H4102_001_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H4102	001	0	1	02	01	H4102_001_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H4102	001	0	1	02	01	H4102_001_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					560.00	33		33																														33							33			33				33			33			
H4102	001	0	1	02	01	H4102_001_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H4102	001	0	1	02	01	H4102_001_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H4123	001	0	1	02	01	H4123_001_0	7	4	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	1	34	1					200.00	33																							33																			33				33			33			
H4123	001	0	1	02	01	H4123_001_0	7	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	1				6.00	12.00	18.00																						6.00	12.00	15.00																		6.00					6.00							
H4123	001	0	1	02	01	H4123_001_0	7	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				34	1		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
H4123	001	0	1	02	01	H4123_001_0	7	3	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	1	34	1		85.00	170.00	255.00																						85.00	170.00	212.50																		85.00					85.00			85.00				
H4123	004	0	1	02	01	H4123_004_0	6	3	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	1	34	1		75.00	150.00	225.00																						75.00	150.00	187.50																		75.00					75.00			75.00				
H4123	004	0	1	02	01	H4123_004_0	6	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				34	1		40.00	80.00	120.00																						40.00	80.00	100.00																		40.00								40.00				
H4123	004	0	1	02	01	H4123_004_0	6	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	1				0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00							
H4123	004	0	1	02	01	H4123_004_0	6	4	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	1	34	1					200.00	33																							33																			33				33			33			
H4125	001	0	1	01	01	H4125_001_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					1570.00	33																							33																			33				33			33			
H4125	001	0	1	01	01	H4125_001_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		95.00		285.00																						95.00		237.50																		95.00					95.00			95.00				
H4125	001	0	1	01	01	H4125_001_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		11.00		33.00																						11.00		22.00																		11.00					11.00			11.00				
H4125	001	0	1	01	01	H4125_001_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		2.00		6.00																						2.00		4.00																		2.00					2.00			2.00				
H4125	001	0	1	01	01	H4125_001_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		45.00		135.00																						45.00		112.50																		45.00					45.00			45.00				
H4141	001	0	1	01	01	H4141_001_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		3.00		9.00																													0.00		0.00					3.00		9.00				3.00					3.00			3.00				
H4141	001	0	1	01	01	H4141_001_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H4141	001	0	1	01	01	H4141_001_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H4141	001	0	1	01	01	H4141_001_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		92.00		276.00																													92.00		266.00					92.00		276.00				92.00					92.00			92.00				
H4141	001	0	1	01	01	H4141_001_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					691.00	33																														33							33					33				33			33	2	3	
H4141	001	0	1	01	01	H4141_001_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		3.00		9.00																													0.00		0.00					3.00		9.00				3.00					3.00			3.00		2	3	1
H4141	001	0	1	01	01	H4141_001_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	2	
H4141	001	0	1	01	01	H4141_001_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H4141	001	0	1	01	01	H4141_001_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		92.00		276.00																													92.00		266.00					92.00		276.00				92.00					92.00			92.00		2	3	
H4141	001	0	1	01	01	H4141_001_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					603.00	33																														33							33					33				33			33			
H4141	003	0	1	01	01	H4141_003_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H4141	003	0	1	01	01	H4141_003_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		43.00		129.00																													43.00		119.00					43.00		129.00				43.00					43.00			43.00				
H4141	003	0	1	01	01	H4141_003_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		92.00		276.00																													92.00		266.00					92.00		276.00				92.00					92.00			92.00				
H4141	003	0	1	01	01	H4141_003_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					478.00	25																														25							25					25				25			25			
H4141	003	0	1	01	01	H4141_003_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H4141	004	0	1	01	01	H4141_004_0	9	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H4141	004	0	1	01	01	H4141_004_0	9	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00				
H4141	004	0	1	01	01	H4141_004_0	9	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H4141	004	0	1	01	01	H4141_004_0	9	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H4141	004	0	1	01	01	H4141_004_0	9	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					761.00	33																														33							33					33				33			33	2	3	
H4141	004	0	1	01	01	H4141_004_0	9	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00		2	3	1
H4141	004	0	1	01	01	H4141_004_0	9	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H4141	004	0	1	01	01	H4141_004_0	9	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H4141	004	0	1	01	01	H4141_004_0	9	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H4141	004	0	1	01	01	H4141_004_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					655.00	33																														33							33					33				33			33			
H4141	005	0	1	01	01	H4141_005_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H4141	005	0	1	01	01	H4141_005_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H4141	005	0	1	01	01	H4141_005_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		35.00		105.00																													35.00		95.00					35.00		105.00				35.00					35.00			35.00				
H4141	005	0	1	01	01	H4141_005_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					465.00	25																														25							25					25				25			25			
H4141	005	0	1	01	01	H4141_005_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		70.00		210.00																													70.00		200.00					70.00		210.00				70.00					70.00			70.00				
H4141	006	0	1	01	01	H4141_006_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00				
H4141	006	0	1	01	01	H4141_006_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00				
H4141	006	0	1	01	01	H4141_006_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					899.00	33																														33							33					33				33			33	2	3	
H4141	006	0	1	01	01	H4141_006_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H4141	006	0	1	01	01	H4141_006_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H4141	006	0	1	01	01	H4141_006_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00		2	2	
H4141	006	0	1	01	01	H4141_006_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00		2	3	1
H4141	006	0	1	01	01	H4141_006_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H4141	006	0	1	01	01	H4141_006_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					785.00	33																														33							33					33				33			33			
H4141	006	0	1	01	01	H4141_006_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H4141	007	0	1	01	01	H4141_007_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		92.00		276.00																													92.00		266.00					92.00		276.00				92.00					92.00			92.00				
H4141	007	0	1	01	01	H4141_007_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					495.00	25																														25							25					25				25			25			
H4141	007	0	1	01	01	H4141_007_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H4141	007	0	1	01	01	H4141_007_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H4141	007	0	1	01	01	H4141_007_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H4141	008	0	1	01	01	H4141_008_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H4141	008	0	1	01	01	H4141_008_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					900.00	33																														33							33					33				33			33	2	3	
H4141	008	0	1	01	01	H4141_008_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H4141	008	0	1	01	01	H4141_008_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H4141	008	0	1	01	01	H4141_008_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H4141	008	0	1	01	01	H4141_008_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H4141	008	0	1	01	01	H4141_008_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					785.00	33																														33							33					33				33			33			
H4141	008	0	1	01	01	H4141_008_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H4141	008	0	1	01	01	H4141_008_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H4141	008	0	1	01	01	H4141_008_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H4141	009	0	1	01	01	H4141_009_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H4141	009	0	1	01	01	H4141_009_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		3.00		9.00																													0.00		0.00					3.00		9.00				3.00					3.00			3.00				
H4141	009	0	1	01	01	H4141_009_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H4141	009	0	1	01	01	H4141_009_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					864.00	33																														33							33					33				33			33	2	3	
H4141	009	0	1	01	01	H4141_009_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H4141	009	0	1	01	01	H4141_009_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H4141	009	0	1	01	01	H4141_009_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	2	
H4141	009	0	1	01	01	H4141_009_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		3.00		9.00																													0.00		0.00					3.00		9.00				3.00					3.00			3.00		2	3	1
H4141	009	0	1	01	01	H4141_009_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					731.00	33																														33							33					33				33			33			
H4141	009	0	1	01	01	H4141_009_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H4141	010	0	1	01	01	H4141_010_0	11	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H4141	010	0	1	01	01	H4141_010_0	11	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H4141	010	0	1	01	01	H4141_010_0	11	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		43.00		129.00																													43.00		119.00					43.00		129.00				43.00					43.00			43.00				
H4141	010	0	1	01	01	H4141_010_0	11	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		94.00		282.00																													94.00		272.00					94.00		282.00				94.00					94.00			94.00				
H4141	010	0	1	01	01	H4141_010_0	11	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					397.00	25																														25							25					25				25			25			
H4141	011	0	1	01	01	H4141_011_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		89.00		267.00																													89.00		257.00					89.00		267.00				89.00					89.00			89.00		2	3	
H4141	011	0	1	01	01	H4141_011_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1286.00	33																														33							33					33				33			33	2	3	
H4141	011	0	1	01	01	H4141_011_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H4141	011	0	1	01	01	H4141_011_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		13.00		39.00																													0.00		0.00					13.00		39.00				13.00					13.00			13.00		2	2	
H4141	011	0	1	01	01	H4141_011_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		2.00		6.00																													0.00		0.00					2.00		6.00				2.00					2.00			2.00		2	3	1
H4141	011	0	1	01	01	H4141_011_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					428.00	33																														33							33					33				33			33			
H4141	011	0	1	01	01	H4141_011_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		89.00		267.00																													89.00		257.00					89.00		267.00				89.00					89.00			89.00				
H4141	011	0	1	01	01	H4141_011_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H4141	011	0	1	01	01	H4141_011_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		13.00		39.00																													0.00		0.00					13.00		39.00				13.00					13.00			13.00				
H4141	011	0	1	01	01	H4141_011_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		2.00		6.00																													0.00		0.00					2.00		6.00				2.00					2.00			2.00				
H4141	012	0	1	01	01	H4141_012_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					2165.00	33																														33							33					33				33			33	2	3	
H4141	012	0	1	01	01	H4141_012_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		89.00		267.00																													89.00		257.00					89.00		267.00				89.00					89.00			89.00		2	3	
H4141	012	0	1	01	01	H4141_012_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H4141	012	0	1	01	01	H4141_012_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H4141	012	0	1	01	01	H4141_012_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		2.00		6.00																													0.00		0.00					2.00		6.00				2.00					2.00			2.00				
H4141	012	0	1	01	01	H4141_012_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					759.00	33																														33							33					33				33			33			
H4141	012	0	1	01	01	H4141_012_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		89.00		267.00																													89.00		257.00					89.00		267.00				89.00					89.00			89.00				
H4141	012	0	1	01	01	H4141_012_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H4141	012	0	1	01	01	H4141_012_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H4141	012	0	1	01	01	H4141_012_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		2.00		6.00																													0.00		0.00					2.00		6.00				2.00					2.00			2.00		2	3	1
H4141	013	0	1	01	01	H4141_013_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					2066.03	33																														33							33					33				33			33	2	3	
H4141	013	0	1	01	01	H4141_013_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00				
H4141	013	0	1	01	01	H4141_013_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H4141	013	0	1	01	01	H4141_013_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H4141	013	0	1	01	01	H4141_013_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		89.00		267.00																													89.00		257.00					89.00		267.00				89.00					89.00			89.00				
H4141	013	0	1	01	01	H4141_013_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					559.61	33																														33							33					33				33			33			
H4141	013	0	1	01	01	H4141_013_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00		2	3	1
H4141	013	0	1	01	01	H4141_013_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H4141	013	0	1	01	01	H4141_013_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H4141	013	0	1	01	01	H4141_013_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		89.00		267.00																													89.00		257.00					89.00		267.00				89.00					89.00			89.00		2	3	
H4152	005	0	1	01	01	H4152_005_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000010001000000100	30	60	90							1			90							30		31					10.00	20.00	30.00																								20.00																		10.00					10.00							
H4152	005	0	1	01	01	H4152_005_0	6	3	Preferred Brand	1	4	000001	1	2	111100000010001000000001	30	60	90							1			90							30				31	14		45.00	90.00	135.00																								112.50																		45.00								45.00				
H4152	005	0	1	01	01	H4152_005_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000010001000000001	30	60	90							1			90							30				31	14		95.00	190.00	285.00																								237.50																		95.00								95.00				
H4152	005	0	1	01	01	H4152_005_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					353.62	33																							33																			33				33			33			
H4152	005	0	1	01	01	H4152_005_0	6	1	Preferred Generic	1	4	001000	1	2	011100000010001000000100	30	60	90							1			90							30		31					3.00	6.00	9.00																								6.00																		3.00					3.00							
H4152	007	0	1	02	01	H4152_007_0	6	1	Preferred Generic	1	4	001000	1	2	011100000010001000000100	30	60	90							1			90							30		31					3.00	6.00	9.00																								6.00																		3.00					3.00							
H4152	007	0	1	02	01	H4152_007_0	6	3	Preferred Brand	1	4	000001	1	2	111100000010001000000001	30	60	90							1			90							30				31	14		45.00	90.00	135.00																								112.50																		45.00								45.00				
H4152	007	0	1	02	01	H4152_007_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000010001000000001	30	60	90							1			90							30				31	14		95.00	190.00	285.00																								237.50																		95.00								95.00				
H4152	007	0	1	02	01	H4152_007_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					340.68	33																							33																			33				33			33			
H4152	007	0	1	02	01	H4152_007_0	6	1	Preferred Generic	3	4	001000	1	2	011100000010001000000100	30	60	90							1			90							30		31					3.00	6.00	9.00																								6.00																		3.00					3.00					1		
H4152	007	0	1	02	01	H4152_007_0	6	2	Non-Preferred Generic	3	4	000100	1	2	011100000010001000000100	30	60	90							1			90							30		31					10.00	20.00	30.00																								20.00																		10.00					10.00					1		
H4152	007	0	1	02	01	H4152_007_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000010001000000100	30	60	90							1			90							30		31					10.00	20.00	30.00																								20.00																		10.00					10.00							
H4152	013	0	1	01	01	H4152_013_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000010001000000001	30	60	90							1			90							30				31	14		95.00	190.00	285.00																								237.50																		95.00								95.00				
H4152	013	0	1	01	01	H4152_013_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					412.34	33																							33																			33				33			33			
H4152	013	0	1	01	01	H4152_013_0	6	3	Preferred Brand	1	4	000001	1	2	111100000010001000000001	30	60	90							1			90							30				31	14		45.00	90.00	135.00																								112.50																		45.00								45.00				
H4152	013	0	1	01	01	H4152_013_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000010001000000100	30	60	90							1			90							30		31					12.00	24.00	36.00																								24.00																		12.00					12.00							
H4152	013	0	1	01	01	H4152_013_0	6	1	Preferred Generic	1	4	001000	1	2	011100000010001000000100	30	60	90							1			90							30		31					4.00	8.00	12.00																								8.00																		4.00					4.00							
H4152	016	0	1	02	01	H4152_016_0	6	3	Preferred Brand	1	4	000001	1	2	111100000010001000000001	30	60	90							1			90							30				31	14		45.00	90.00	135.00																								112.50																		45.00								45.00				
H4152	016	0	1	02	01	H4152_016_0	6	1	Preferred Generic	1	4	001000	1	2	011100000010001000000100	30	60	90							1			90							30		31					5.00	10.00	15.00																								10.00																		5.00					5.00							
H4152	016	0	1	02	01	H4152_016_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000010001000000100	30	60	90							1			90							30		31					15.00	30.00	45.00																								30.00																		15.00					15.00							
H4152	016	0	1	02	01	H4152_016_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000010001000000001	30	60	90							1			90							30				31	14		95.00	190.00	285.00																								237.50																		95.00								95.00				
H4152	016	0	1	02	01	H4152_016_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					384.30	33																							33																			33				33			33			
H4155	001	0	1	01	01	H4155_001_0	9	1	Generic	3	4	010000	1	2	010100000010101000000110	30		90							1	30		90							30		31	1				0.00		0.00																						0.00		0.00																		0.00					0.00					1		
H4155	001	0	1	01	01	H4155_001_0	9	3	Non-Preferred Brand	1	4	100000	3	2	110100000010101000000001	30		90							1	30		90							30				31	1		25.00		50.00																						25.00		50.00																		25.00								25.00				
H4155	001	0	1	01	01	H4155_001_0	9	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							1	30		90							30				31	1		10.00		20.00																						10.00		20.00																		10.00								10.00				
H4155	001	0	1	01	01	H4155_001_0	9	1	Generic	1	4	010000	1	2	010100000010101000000110	30		90							1	30		90							30		31	1				0.00		0.00																						0.00		0.00																		0.00					0.00							
H4155	001	0	1	01	01	H4155_001_0	9	4	Specialty Tier	1	4	100000	1	1	110100000010101000000001	30		90							1	30		90							30				31	1					0.00	33		33																					33		33																	33							33			
H4155	003	0	1	01	01	H4155_003_0	7	4	Specialty Tier	1	4	100000	1	1	110100000010101000000001	30		90							1	30		90							30				31	1					290.00	25		25																					25		25																	25							25			
H4155	003	0	1	01	01	H4155_003_0	7	2	Preferred Brand	1	4	000001	1	1	110100000010101000000001	30		90							1	30		90							30				31	1					290.00	25		25																					25		25																	25							25			
H4155	003	0	1	01	01	H4155_003_0	7	3	Non-Preferred Brand	1	4	100000	3	1	110100000010101000000001	30		90							1	30		90							30				31	1					290.00	25		25																					25		25																	25							25			
H4155	003	0	1	01	01	H4155_003_0	7	1	Generic	1	4	010000	1	2	010100000010101000000110	30		90							1	30		90							30		31	1				0.00		0.00																						0.00		0.00																		0.00					0.00							
H4199	001	0	1	01	01	H4199_001_0	11	1	Generic	1	4	010000	3	2	010100000010001000000110	30		90							1			90							30		31	14				0.00		0.00																								0.00																		0.00				0.00	0.00							
H4199	001	0	1	01	01	H4199_001_0	11	2	Preferred Brand	1	4	000001	3	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00							0.00	0.00				
H4199	001	0	1	01	01	H4199_001_0	11	1	Generic	3	4	010000	3	2	010100000010001000000110	30		90							1			90							30		31	14				0.00		0.00																								0.00																		0.00				0.00	0.00					1		
H4199	001	0	1	01	01	H4199_001_0	11	4	Specialty Tier	1	4	010010	3	1	110100000010001000000111	30		90							1			90							30		31	14	31	14					33.00	33		33																							33																	33				33			33			
H4199	001	0	1	01	01	H4199_001_0	11	3	Non-Preferred Brand	1	4	100000	3	2	110100000010001000000001	30		90							1			90							30				31	14		20.00		60.00																								60.00																		20.00							.60	20.00				
H4199	002	0	1	01	01	H4199_002_0	14	4	Specialty Tier	1	4	010010	3	1	110100000010001000000111	30		90							1			90							30		31	14	31	14					33.00	33		33																							33																	33				33			33			
H4199	002	0	1	01	01	H4199_002_0	14	1	Generic	3	4	010000	3	2	010100000010001000000110	30		90							1			90							30		31	14				0.00		0.00																								0.00																		0.00				0.00	0.00					1		
H4199	002	0	1	01	01	H4199_002_0	14	1	Generic	1	4	010000	3	2	010100000010001000000110	30		90							1			90							30		31	14				0.00		0.00																								0.00																		0.00				0.00	0.00							
H4199	002	0	1	01	01	H4199_002_0	14	2	Preferred Brand	1	4	000001	3	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00							0.00	0.00				
H4199	002	0	1	01	01	H4199_002_0	14	3	Non-Preferred Brand	1	4	100000	3	2	110100000010001000000001	30		90							1			90							30				31	14		20.00		60.00																								60.00																		20.00							.60	20.00				
H4199	005	0	1	01	01	H4199_005_0	14	3	Non-Preferred Brand	1	4	100000	3	2	110100000010001000000001	30		90							1			90							30				31	14		20.00		60.00																								60.00																		20.00							.60	20.00				
H4199	005	0	1	01	01	H4199_005_0	14	4	Specialty Tier	1	4	010010	3	1	110100000010001000000111	30		90							1			90							30		31	14	31	14					33.00	33		33																							33																	33				33			33			
H4199	005	0	1	01	01	H4199_005_0	14	1	Generic	1	4	010000	3	2	010100000010001000000110	30		90							1			90							30		31	14				0.00		0.00																								0.00																		0.00				0.00	0.00							
H4199	005	0	1	01	01	H4199_005_0	14	1	Generic	3	4	010000	3	2	010100000010001000000110	30		90							1			90							30		31	14				0.00		0.00																								0.00																		0.00				0.00	0.00					1		
H4199	005	0	1	01	01	H4199_005_0	14	2	Preferred Brand	1	4	000001	3	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00							0.00	0.00				
H4199	007	0	1	01	01	H4199_007_0	9	1	Generic	3	4	010000	3	2	010100000010001000000110	30		90							1			90							30		31	14				0.00		0.00																								0.00																		0.00				0.00	0.00					1		
H4199	007	0	1	01	01	H4199_007_0	9	1	Generic	1	4	010000	3	2	010100000010001000000110	30		90							1			90							30		31	14				0.00		0.00																								0.00																		0.00				0.00	0.00							
H4199	007	0	1	01	01	H4199_007_0	9	2	Preferred Brand	1	4	000001	3	2	110100000010001000000001	30		90							1			90							30				31	14		10.00		30.00																								30.00																		10.00								10.00				
H4199	007	0	1	01	01	H4199_007_0	9	3	Non-Preferred Brand	1	4	100000	3	2	110100000010001000000001	30		90							1			90							30				31	14		40.00		120.00																								120.00																		40.00								40.00				
H4199	007	0	1	01	01	H4199_007_0	9	4	Specialty Tier	1	4	010010	3	1	110100000010001000000111	30		90							1			90							30		31	14	31	14					600.00	33		33																							33																	33				33			33			
H4199	008	0	1	01	01	H4199_008_0	10	1	Generic	3	4	010000	3	2	010100000010001000000110	30		90							1			90							30		31	14				0.00		0.00																								0.00																		0.00				0.00	0.00					1		
H4199	008	0	1	01	01	H4199_008_0	10	3	Non-Preferred Brand	1	4	100000	3	2	110100000010001000000001	30		90							1			90							30				31	14		60.00		180.00																								180.00																		60.00								60.00				
H4199	008	0	1	01	01	H4199_008_0	10	2	Preferred Brand	1	4	000001	3	2	110100000010001000000001	30		90							1			90							30				31	14		20.00		60.00																								60.00																		20.00								20.00				
H4199	008	0	1	01	01	H4199_008_0	10	1	Generic	1	4	010000	3	2	010100000010001000000110	30		90							1			90							30		31	14				0.00		0.00																								0.00																		0.00				0.00	0.00							
H4199	008	0	1	01	01	H4199_008_0	10	4	Specialty Tier	1	4	010010	3	1	110100000010001000000111	30		90							1			90							30		31	14	31	14					600.00	33		33																							33																	33				33			33			
H4199	010	0	1	01	01	H4199_010_0	10	1	Generic	3	4	010000	3	2	010100000010001000000110	30		90							1			90							30		31	14				0.00		0.00																								0.00																		0.00				0.00	0.00					1		
H4199	010	0	1	01	01	H4199_010_0	10	4	Specialty Tier	1	4	010010	3	1	110100000010001000000111	30		90							1			90							30		31	14	31	14					600.00	33		33																							33																	33				33			33			
H4199	010	0	1	01	01	H4199_010_0	10	3	Non-Preferred Brand	1	4	100000	3	2	110100000010001000000001	30		90							1			90							30				31	14		40.00		120.00																								120.00																		40.00								40.00				
H4199	010	0	1	01	01	H4199_010_0	10	2	Preferred Brand	1	4	000001	3	2	110100000010001000000001	30		90							1			90							30				31	14		10.00		30.00																								30.00																		10.00								10.00				
H4199	010	0	1	01	01	H4199_010_0	10	1	Generic	1	4	010000	3	2	010100000010001000000110	30		90							1			90							30		31	14				0.00		0.00																								0.00																		0.00				0.00	0.00							
H4199	012	0	1	01	01	H4199_012_0	10	3	Non-Preferred Brand	1	4	100000	3	2	110100000010001000000001	30		90							1			90							30				31	14		40.00		120.00																								120.00																		40.00								40.00				
H4199	012	0	1	01	01	H4199_012_0	10	4	Specialty Tier	1	4	010010	3	1	110100000010001000000111	30		90							1			90							30		31	14	31	14					600.00	33		33																							33																	33				33			33			
H4199	012	0	1	01	01	H4199_012_0	10	2	Preferred Brand	1	4	000001	3	2	110100000010001000000001	30		90							1			90							30				31	14		10.00		30.00																								30.00																		10.00								10.00				
H4199	012	0	1	01	01	H4199_012_0	10	1	Generic	3	4	010000	3	2	010100000010001000000110	30		90							1			90							30		31	14				0.00		0.00																								0.00																		0.00				0.00	0.00					1		
H4199	012	0	1	01	01	H4199_012_0	10	1	Generic	1	4	010000	3	2	010100000010001000000110	30		90							1			90							30		31	14				0.00		0.00																								0.00																		0.00				0.00	0.00							
H4199	013	0	1	01	01	H4199_013_0	11	1	Generic	3	4	010000	3	2	010100000010001000000110	30		90							1			90							30		31	14				0.00		0.00																								0.00																		0.00				0.00	0.00					1		
H4199	013	0	1	01	01	H4199_013_0	11	4	Specialty Tier	1	4	010010	3	1	110100000010001000000111	30		90							1			90							30		31	14	31	14					600.00	33		33																							33																	33				33			33			
H4199	013	0	1	01	01	H4199_013_0	11	3	Non-Preferred Brand	1	4	100000	3	2	110100000010001000000001	30		90							1			90							30				31	14		60.00		180.00																								180.00																		60.00								60.00				
H4199	013	0	1	01	01	H4199_013_0	11	2	Preferred Brand	1	4	000001	3	2	110100000010001000000001	30		90							1			90							30				31	14		20.00		60.00																								60.00																		20.00								20.00				
H4199	013	0	1	01	01	H4199_013_0	11	1	Generic	1	4	010000	3	2	010100000010001000000110	30		90							1			90							30		31	14				0.00		0.00																								0.00																		0.00				0.00	0.00							
H4199	015	0	1	01	01	H4199_015_0	12	3	Non-Preferred Brand	1	4	100000	3	2	110100000010001000000001	30		90							1			90							30				31	14		40.00		120.00																								120.00																		40.00								40.00				
H4199	015	0	1	01	01	H4199_015_0	12	4	Specialty Tier	1	4	010010	3	1	110100000010001000000111	30		90							1			90							30		31	14	31	14					600.00	33		33																							33																	33				33			33			
H4199	015	0	1	01	01	H4199_015_0	12	1	Generic	3	4	010000	3	2	010100000010001000000110	30		90							1			90							30		31	14				0.00		0.00																								0.00																		0.00				0.00	0.00					1		
H4199	015	0	1	01	01	H4199_015_0	12	2	Preferred Brand	1	4	000001	3	2	110100000010001000000001	30		90							1			90							30				31	14		10.00		30.00																								30.00																		10.00								10.00				
H4199	015	0	1	01	01	H4199_015_0	12	1	Generic	1	4	010000	3	2	010100000010001000000110	30		90							1			90							30		31	14				0.00		0.00																								0.00																		0.00				0.00	0.00							
H4199	017	0	1	01	01	H4199_017_0	9	4	Specialty Tier	1	4	010010	3	1	110100000010001000000111	30		90							1			90							30		31	14	31	14					600.00	33		33																							33																	33				33			33			
H4199	017	0	1	01	01	H4199_017_0	9	1	Generic	3	4	010000	3	2	010100000010001000000110	30		90							1			90							30		31	14				0.00		0.00																								0.00																		0.00				0.00	0.00					1		
H4199	017	0	1	01	01	H4199_017_0	9	1	Generic	1	4	010000	3	2	010100000010001000000110	30		90							1			90							30		31	14				0.00		0.00																								0.00																		0.00				0.00	0.00							
H4199	017	0	1	01	01	H4199_017_0	9	2	Preferred Brand	1	4	000001	3	2	110100000010001000000001	30		90							1			90							30				31	14		10.00		30.00																								30.00																		10.00								10.00				
H4199	017	0	1	01	01	H4199_017_0	9	3	Non-Preferred Brand	1	4	100000	3	2	110100000010001000000001	30		90							1			90							30				31	14		40.00		120.00																								120.00																		40.00								40.00				
H4199	018	0	1	01	01	H4199_018_0	10	1	Generic	3	4	010000	3	2	010100000010001000000110	30		90							1			90							30		31	14				0.00		0.00																								0.00																		0.00				0.00	0.00					1		
H4199	018	0	1	01	01	H4199_018_0	10	4	Specialty Tier	1	4	010010	3	1	110100000010001000000111	30		90							1			90							30		31	14	31	14					600.00	33		33																							33																	33				33			33			
H4199	018	0	1	01	01	H4199_018_0	10	3	Non-Preferred Brand	1	4	100000	3	2	110100000010001000000001	30		90							1			90							30				31	14		60.00		180.00																								180.00																		60.00								60.00				
H4199	018	0	1	01	01	H4199_018_0	10	1	Generic	1	4	010000	3	2	010100000010001000000110	30		90							1			90							30		31	14				0.00		0.00																								0.00																		0.00				0.00	0.00							
H4199	018	0	1	01	01	H4199_018_0	10	2	Preferred Brand	1	4	000001	3	2	110100000010001000000001	30		90							1			90							30				31	14		20.00		60.00																								60.00																		20.00								20.00				
H4199	020	0	1	01	01	H4199_020_0	11	4	Specialty Tier	1	4	010010	3	1	110100000010001000000111	30		90							1			90							30		31	14	31	14					600.00	33		33																							33																	33				33			33			
H4199	020	0	1	01	01	H4199_020_0	11	3	Non-Preferred Brand	1	4	100000	3	2	110100000010001000000001	30		90							1			90							30				31	14		40.00		120.00																								120.00																		40.00								40.00				
H4199	020	0	1	01	01	H4199_020_0	11	2	Preferred Brand	1	4	000001	3	2	110100000010001000000001	30		90							1			90							30				31	14		10.00		30.00																								30.00																		10.00								10.00				
H4199	020	0	1	01	01	H4199_020_0	11	1	Generic	1	4	010000	3	2	010100000010001000000110	30		90							1			90							30		31	14				0.00		0.00																								0.00																		0.00				0.00	0.00							
H4199	020	0	1	01	01	H4199_020_0	11	1	Generic	3	4	010000	3	2	010100000010001000000110	30		90							1			90							30		31	14				0.00		0.00																								0.00																		0.00				0.00	0.00					1		
H4209	001	0	1	04	01	H4209_001_0	9	2	Preferred Brand	1	3	000001		2	110100000010000101101001	31		90							1				31		90	31		90	31				31	14		45.00		135.00																													45.00		112.50					45.00		135.00				45.00								45.00				
H4209	001	0	1	04	01	H4209_001_0	9	4	Specialty Tier	1	3	010010		1	110100000010000101101101	31		90							1				31		90	31		90	31		31		31	14					28.00	28		28																												28		28					28		28			28				28			28			
H4209	001	0	1	04	01	H4209_001_0	9	3	Non-Preferred Brand	1	3	100000		2	110100000010000101101001	31		90							1				31		90	31		90	31				31	14		85.00		255.00																													85.00		212.50					85.00		255.00				85.00								85.00				
H4209	001	0	1	04	01	H4209_001_0	9	1	Generic	1	3	010000		2	010100000010000101101100	31		90							1				31		90	31		90	31		31					9.00		27.00																													9.00		22.50					9.00		27.00				9.00					9.00							
H4209	003	0	1	04	01	H4209_003_0	10	1	Generic	1	3	010000		2	010100000010000101101100	31		90							1				31		90	31		90	31		31					9.00		27.00																													9.00		22.50					9.00		27.00				9.00					9.00							
H4209	003	0	1	04	01	H4209_003_0	10	4	Specialty Tier	1	3	010010		1	110100000010000101101101	31		90							1				31		90	31		90	31		31		31	14					28.00	28		28																												28		28					28		28			28				28			28			
H4209	003	0	1	04	01	H4209_003_0	10	2	Preferred Brand	1	3	000001		2	110100000010000101101001	31		90							1				31		90	31		90	31				31	14		45.00		135.00																													45.00		112.50					45.00		135.00				45.00								45.00				
H4209	003	0	1	04	01	H4209_003_0	10	3	Non-Preferred Brand	1	3	100000		2	110100000010000101101001	31		90							1				31		90	31		90	31				31	14		85.00		255.00																													85.00		212.50					85.00		255.00				85.00								85.00				
H4209	009	0	1	04	01	H4209_009_0	10	4	Specialty Tier	1	3	010010		1	110100000010000101101101	31		90							1				31		90	31		90	31		31		31	14					28.00	28		28																												28		28					28		28			28				28			28			
H4209	009	0	1	04	01	H4209_009_0	10	3	Non-Preferred Brand	1	3	100000		2	110100000010000101101001	31		90							1				31		90	31		90	31				31	14		83.00		249.00																													83.00		207.50					83.00		249.00				83.00								83.00				
H4209	009	0	1	04	01	H4209_009_0	10	2	Preferred Brand	1	3	000001		2	110100000010000101101001	31		90							1				31		90	31		90	31				31	14		45.00		135.00																													45.00		112.50					45.00		135.00				45.00								45.00				
H4209	009	0	1	04	01	H4209_009_0	10	1	Generic	1	3	010000		2	010100000010000101101100	31		90							1				31		90	31		90	31		31					9.00		27.00																													9.00		22.50					9.00		27.00				9.00					9.00							
H4211	001	0	1	01	01	H4211_001_0	6	3	Preferred Brand	1	4	000001	1	1	111100000010111000000001	31	62	93							2	31	62	93							31				31	1					48.00	25	25	25																					25	25	25																	25							25			
H4211	001	0	1	01	01	H4211_001_0	6	4	Non-Preferred Brand	1	4	100000	1	1	111100000010111000000001	31	62	93							2	31	62	93							31				31	1					58.00	25	25	25																					25	25	25																	25							25			
H4211	001	0	1	01	01	H4211_001_0	6	5	Specialty Tier	1	4	100100	1	1	111100000010111000000111	31	62	93							2	31	62	93							31		31	1	31	1					455.00	25	25	25																					25	25	25																	25				25			25			
H4211	001	0	1	01	01	H4211_001_0	6	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	31	62	93							2	31	62	93							31		31	1				0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00					1		
H4211	001	0	1	01	01	H4211_001_0	6	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	31	62	93							2	31	62	93							31		31	1				0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00							
H4211	001	0	1	01	01	H4211_001_0	6	2	Non-Preferred Generic	1	4	000100	1	1	011100000010111000000110	31	62	93							2	31	62	93							31		31	1							7.00	25	25	25																					25	25	25																	25				25						
H4211	003	0	1	01	01	H4211_003_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	31	62	93							2	31	62	93							31				31	1		95.00	190.00	285.00																						95.00	142.50	190.00																		95.00								95.00				
H4211	003	0	1	01	01	H4211_003_0	6	3	Preferred Brand	1	4	000001	1	2	111100000010111000000001	31	62	93							2	31	62	93							31				31	1		45.00	90.00	135.00																						45.00	67.50	90.00																		45.00								45.00				
H4211	003	0	1	01	01	H4211_003_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	31	62	93							2	31	62	93							31		31	1				6.00	12.00	18.00																						6.00	9.00	12.00																		6.00					6.00							
H4211	003	0	1	01	01	H4211_003_0	6	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	31	62	93							2	31	62	93							31		31	1				4.00	8.00	12.00																						4.00	6.00	8.00																		4.00					4.00					1		
H4211	003	0	1	01	01	H4211_003_0	6	5	Specialty Tier	1	4	100100	1	1	111100000010111000000111	31	62	93							2	31	62	93							31		31	1	31	1					578.00	33	33	33																					33	33	33																	33				33			33			
H4211	003	0	1	01	01	H4211_003_0	6	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	31	62	93							2	31	62	93							31		31	1				4.00	8.00	12.00																						4.00	6.00	8.00																		4.00					4.00							
H4213	004	0	1	09	04	H4213_004_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	34		90							1	34		90							34		34					2.00		3.00																						2.00		3.00																		2.00					2.00							
H4213	004	0	1	09	04	H4213_004_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	34		90							1	34		90							34		34					11.00		27.50																						11.00		27.50																		11.00					11.00							
H4213	004	0	1	09	04	H4213_004_0	9	4	Non-Preferred Brand	1	4	100000	1	1	110100000010101000000001	34		90							1	34		90							34				34	14					94.61	42		42																					42		42																	42							42			
H4213	004	0	1	09	04	H4213_004_0	9	3	Preferred Brand	1	4	000001	1	1	110100000010101000000001	34		90							1	34		90							34				34	14					39.71	25		25																					25		25																	25							25			
H4213	004	0	1	09	04	H4213_004_0	9	5	Specialty Tier	1	4	010010	1	1	110100000010101000000101	34		90							1	34		90							34		34		34	14					354.35	25		25																					25		25																	25				25			25			
H4213	005	0	1	09	04	H4213_005_0	8	5	Specialty Tier	1	4	010010	1	1	110100000010101000000101	34		90							1	34		90							34		34		34	14					354.35	25		25																					25		25																	25				25			25			
H4213	005	0	1	09	04	H4213_005_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	34		90							1	34		90							34		34					2.00		3.00																						2.00		3.00																		2.00					2.00							
H4213	005	0	1	09	04	H4213_005_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	34		90							1	34		90							34		34					11.00		27.50																						11.00		27.50																		11.00					11.00							
H4213	005	0	1	09	04	H4213_005_0	8	3	Preferred Brand	1	4	000001	1	1	110100000010101000000001	34		90							1	34		90							34				34	14					39.71	25		25																					25		25																	25							25			
H4213	005	0	1	09	04	H4213_005_0	8	4	Non-Preferred Brand	1	4	100000	1	1	110100000010101000000001	34		90							1	34		90							34				34	14					94.61	42		42																					42		42																	42							42			
H4213	006	0	1	09	04	H4213_006_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	34		90							1	34		90							34		34					11.00		27.50																						11.00		27.50																		11.00					11.00							
H4213	006	0	1	09	04	H4213_006_0	9	4	Non-Preferred Brand	1	4	100000	1	1	110100000010101000000001	34		90							1	34		90							34				34	14					94.61	42		42																					42		42																	42							42			
H4213	006	0	1	09	04	H4213_006_0	9	3	Preferred Brand	1	4	000001	1	1	110100000010101000000001	34		90							1	34		90							34				34	14					39.71	25		25																					25		25																	25							25			
H4213	006	0	1	09	04	H4213_006_0	9	5	Specialty Tier	1	4	010010	1	1	110100000010101000000101	34		90							1	34		90							34		34		34	14					354.35	25		25																					25		25																	25				25			25			
H4213	006	0	1	09	04	H4213_006_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	34		90							1	34		90							34		34					2.00		3.00																						2.00		3.00																		2.00					2.00							
H4213	007	0	1	09	04	H4213_007_0	9	5	Specialty Tier	1	4	010010	1	1	110100000010101000000101	34		90							1	34		90							34		34		34	14					354.35	25		25																					25		25																	25				25			25			
H4213	007	0	1	09	04	H4213_007_0	9	4	Non-Preferred Brand	1	4	100000	1	1	110100000010101000000001	34		90							1	34		90							34				34	14					94.61	42		42																					42		42																	42							42			
H4213	007	0	1	09	04	H4213_007_0	9	3	Preferred Brand	1	4	000001	1	1	110100000010101000000001	34		90							1	34		90							34				34	14					39.71	25		25																					25		25																	25							25			
H4213	007	0	1	09	04	H4213_007_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	34		90							1	34		90							34		34					2.00		3.00																						2.00		3.00																		2.00					2.00							
H4213	007	0	1	09	04	H4213_007_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	34		90							1	34		90							34		34					11.00		27.50																						11.00		27.50																		11.00					11.00							
H4213	010	0	1	09	04	H4213_010_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	34		90							1	34		90							34		34					11.00		27.50																						11.00		27.50																		11.00					11.00							
H4213	010	0	1	09	04	H4213_010_0	8	3	Preferred Brand	1	4	000001	1	1	110100000010101000000001	34		90							1	34		90							34				34	14					39.71	25		25																					25		25																	25							25			
H4213	010	0	1	09	04	H4213_010_0	8	4	Non-Preferred Brand	1	4	100000	1	1	110100000010101000000001	34		90							1	34		90							34				34	14					94.61	42		42																					42		42																	42							42			
H4213	010	0	1	09	04	H4213_010_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	34		90							1	34		90							34		34					2.00		3.00																						2.00		3.00																		2.00					2.00							
H4213	010	0	1	09	04	H4213_010_0	8	5	Specialty Tier	1	4	010010	1	1	110100000010101000000101	34		90							1	34		90							34		34		34	14					354.35	25		25																					25		25																	25				25			25			
H4268	002	0	1	09	04	H4268_002_0	7	4	Specialty Tier	1	4	100100	1	1	110100000010101000000111	30		90							1	30		90							30		31	14	31	14					622.78	33		33																					33		33																	33				33			33			
H4268	002	0	1	09	04	H4268_002_0	7	3	Non-Preferred Brand	1	4	100100	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		78.00		234.00																						78.00		195.00																		78.00					78.00			78.00				
H4268	002	0	1	09	04	H4268_002_0	7	2	Preferred Brand	1	4	000101	1	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		44.00		132.00																						44.00		110.00																		44.00					44.00			44.00				
H4268	002	0	1	09	04	H4268_002_0	7	1	Preferred Generic	1	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		4.00		12.00																						4.00		10.00																		4.00					4.00			4.00				
H4270	003	0	1	02	01	H4270_003_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110100000001001000000001	30		90							1			90								29			31	14		80.00		200.00																								160.00																			80.00							80.00				
H4270	003	0	1	02	01	H4270_003_0	7	5	Specialty Tier	1	4	010010	1	1	110100000001001000000111	30		90							1			90								29	31	14	31	14					1185.03	25		25																							25																		25			25			25			
H4270	003	0	1	02	01	H4270_003_0	7	3	Preferred Brand	1	4	000001	1	2	110100000001001000000001	30		90							1			90								29			31	14		40.00		100.00																								80.00																			40.00							40.00				
H4270	003	0	1	02	01	H4270_003_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000001001000000110	30		90							1			90								29	31	14				10.00		25.00																								20.00																			10.00				10.00							
H4270	003	0	1	02	01	H4270_003_0	7	1	Preferred Generic	1	4	001000	1	2	010100000001001000000110	30		90							1			90								29	31	14				5.00		12.50																								10.00																			5.00				5.00							
H4270	006	0	1	02	01	H4270_006_0	9	1	Preferred Generic	1	4	001000	1	2	010100000001001000000110	30		90							1			90								29	31	14				5.00		15.00																								10.00																			5.00				5.00							
H4270	006	0	1	02	01	H4270_006_0	9	5	Specialty Tier	1	4	010010	1	1	110100000001001000000111	30		90							1			90								29	31	14	31	14					1564.24	33		33																							33																		33			33			33			
H4270	006	0	1	02	01	H4270_006_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000001001000000110	30		90							1			90								29	31	14				20.00		60.00																								40.00																			20.00				20.00							
H4270	006	0	1	02	01	H4270_006_0	9	3	Preferred Brand	1	4	000001	1	2	110100000001001000000001	30		90							1			90								29			31	14		45.00		135.00																								90.00																			45.00							45.00				
H4270	006	0	1	02	01	H4270_006_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000001001000000001	30		90							1			90								29			31	14		90.00		270.00																								180.00																			90.00							90.00				
H4279	001	0	1	01	01	H4279_001_0	10	1	Generic	1	2	010000		2	010100000010001000000100	31		90							1			90							31		31					6.00		18.00																								18.00																		6.00					6.00							
H4279	001	0	1	01	01	H4279_001_0	10	2	Preferred Brand	1	2	000001		2	110100000010001000000001	31		90							1			90							31				31	14		34.00		102.00																								102.00																		34.00								34.00				
H4279	001	0	1	01	01	H4279_001_0	10	3	Non-Preferred Brand	1	2	100000		2	110100000010001000000001	31		90							1			90							31				31	14		75.00		225.00																								225.00																		75.00								75.00				
H4279	001	0	1	01	01	H4279_001_0	10	4	Specialty Tier	1	2	110001		1	110000000010000000000101	31																			31		31		31	14					440.00	25																																										25				25			25			
H4279	001	0	1	01	01	H4279_001_0	10	5	Select Care Drugs	1	2	010000		2	010100000010001000000100	31		90							1			90							31		31					0.00		0.00																								0.00																		0.00					0.00							
H4346	001	0	1	01	01	H4346_001_0	10	4	Non-Preferred Brand	3	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00		2		
H4346	001	0	1	01	01	H4346_001_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H4346	001	0	1	01	01	H4346_001_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					3.00		9.00																								7.50																		3.00					3.00							
H4346	001	0	1	01	01	H4346_001_0	10	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								87.50																		35.00								35.00				
H4346	001	0	1	01	01	H4346_001_0	10	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H4346	001	0	1	01	01	H4346_001_0	10	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H4346	001	0	1	01	01	H4346_001_0	10	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		10.00		30.00																								25.00																		10.00								10.00				
H4346	001	0	1	01	01	H4346_001_0	10	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H4346	001	0	1	01	01	H4346_001_0	10	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					3.00		9.00																								7.50																		3.00					3.00					1		
H4346	001	0	1	01	01	H4346_001_0	10	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								87.50																		35.00								35.00		2		
H4346	003	0	1	01	01	H4346_003_0	11	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					3.00		9.00																								7.50																		3.00					3.00							
H4346	003	0	1	01	01	H4346_003_0	11	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H4346	003	0	1	01	01	H4346_003_0	11	6	Select Care Drugs	3	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00		1		
H4346	003	0	1	01	01	H4346_003_0	11	4	Non-Preferred Brand	3	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00		2		
H4346	003	0	1	01	01	H4346_003_0	11	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								87.50																		35.00								35.00		2		
H4346	003	0	1	01	01	H4346_003_0	11	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								87.50																		35.00								35.00				
H4346	003	0	1	01	01	H4346_003_0	11	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H4346	003	0	1	01	01	H4346_003_0	11	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00				
H4346	003	0	1	01	01	H4346_003_0	11	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H4346	003	0	1	01	01	H4346_003_0	11	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H4346	003	0	1	01	01	H4346_003_0	11	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					3.00		9.00																								7.50																		3.00					3.00					1		
H4346	005	0	1	01	01	H4346_005_0	11	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H4346	005	0	1	01	01	H4346_005_0	11	6	Select Care Drugs	3	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00		1		
H4346	005	0	1	01	01	H4346_005_0	11	4	Non-Preferred Brand	3	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00		2		
H4346	005	0	1	01	01	H4346_005_0	11	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								87.50																		35.00								35.00		2		
H4346	005	0	1	01	01	H4346_005_0	11	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					3.00		9.00																								7.50																		3.00					3.00					1		
H4346	005	0	1	01	01	H4346_005_0	11	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H4346	005	0	1	01	01	H4346_005_0	11	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00				
H4346	005	0	1	01	01	H4346_005_0	11	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H4346	005	0	1	01	01	H4346_005_0	11	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H4346	005	0	1	01	01	H4346_005_0	11	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					3.00		9.00																								7.50																		3.00					3.00							
H4346	005	0	1	01	01	H4346_005_0	11	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								87.50																		35.00								35.00				
H4346	006	0	1	01	01	H4346_006_0	11	4	Non-Preferred Brand	3	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00		2		
H4346	006	0	1	01	01	H4346_006_0	11	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								87.50																		35.00								35.00		2		
H4346	006	0	1	01	01	H4346_006_0	11	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					3.00		9.00																								7.50																		3.00					3.00					1		
H4346	006	0	1	01	01	H4346_006_0	11	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H4346	006	0	1	01	01	H4346_006_0	11	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00				
H4346	006	0	1	01	01	H4346_006_0	11	6	Select Care Drugs	3	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00		1		
H4346	006	0	1	01	01	H4346_006_0	11	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H4346	006	0	1	01	01	H4346_006_0	11	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								87.50																		35.00								35.00				
H4346	006	0	1	01	01	H4346_006_0	11	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					3.00		9.00																								7.50																		3.00					3.00							
H4346	006	0	1	01	01	H4346_006_0	11	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H4346	006	0	1	01	01	H4346_006_0	11	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H4346	007	0	1	01	01	H4346_007_0	11	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H4346	007	0	1	01	01	H4346_007_0	11	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		10.00		30.00																								25.00																		10.00								10.00				
H4346	007	0	1	01	01	H4346_007_0	11	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		95.00		285.00																								237.50																		95.00								95.00				
H4346	007	0	1	01	01	H4346_007_0	11	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		45.00		135.00																								112.50																		45.00								45.00				
H4346	007	0	1	01	01	H4346_007_0	11	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								12.50																		5.00					5.00							
H4346	007	0	1	01	01	H4346_007_0	11	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					3.00		9.00																								7.50																		3.00					3.00							
H4346	008	0	1	01	01	H4346_008_0	10	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					330.00	33																							33																			33				33			33			
H4346	008	0	1	01	01	H4346_008_0	10	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00				
H4346	008	0	1	01	01	H4346_008_0	10	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								87.50																		35.00								35.00				
H4346	008	0	1	01	01	H4346_008_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					3.00		9.00																								7.50																		3.00					3.00							
H4346	008	0	1	01	01	H4346_008_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H4346	008	0	1	01	01	H4346_008_0	10	6	Select Care Drugs	3	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00		1		
H4346	008	0	1	01	01	H4346_008_0	10	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H4346	008	0	1	01	01	H4346_008_0	10	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					3.00		9.00																								7.50																		3.00					3.00					1		
H4346	008	0	1	01	01	H4346_008_0	10	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								87.50																		35.00								35.00		2		
H4346	008	0	1	01	01	H4346_008_0	10	4	Non-Preferred Brand	3	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								212.50																		85.00								85.00		2		
H4346	008	0	1	01	01	H4346_008_0	10	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00				
H4406	001	0	1	01	01	H4406_001_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															0.00							9.00				3.00					3.00							
H4406	001	0	1	01	01	H4406_001_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H4406	001	0	1	01	01	H4406_001_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H4406	001	0	1	01	01	H4406_001_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															0.00							18.00				6.00					6.00							
H4406	001	0	1	01	01	H4406_001_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					430.00	33		33																														33							33			33				33			33			
H4407	002	0	1	01	01	H4407_002_0	8	2	Non-Preferred Generic	1	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		10.00	20.00	30.00																								21.00																		10.00					10.00			10.00				
H4407	002	0	1	01	01	H4407_002_0	8	2	Non-Preferred Generic	3	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		10.00	20.00	30.00																								21.00																		10.00					10.00			10.00		2	2	
H4407	002	0	1	01	01	H4407_002_0	8	1	Preferred Generic	3	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					3.00	6.00	9.00																								0.00																		3.00					3.00					1		
H4407	002	0	1	01	01	H4407_002_0	8	5	Specialty Tier	1	4	010010	1	1	111100000010001000000101	30	60	90							2			90							30		31		31	14					285.83	33	33	33																							33																	33				33			33			
H4407	002	0	1	01	01	H4407_002_0	8	4	Non-Preferred Brand	1	4	100100	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		85.00	170.00	255.00																								245.00																		85.00					85.00			85.00				
H4407	002	0	1	01	01	H4407_002_0	8	3	Preferred Brand	1	4	000001	1	2	111100000010001000000001	30	60	90							2			90							30				31	14		45.00	90.00	135.00																								125.00																		45.00								45.00				
H4407	002	0	1	01	01	H4407_002_0	8	1	Preferred Generic	1	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					3.00	6.00	9.00																								0.00																		3.00					3.00							
H4407	022	0	1	02	01	H4407_022_0	7	2	Non-Preferred Generic	1	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		10.00	20.00	30.00																								21.00																		10.00					10.00			10.00				
H4407	022	0	1	02	01	H4407_022_0	7	2	Non-Preferred Generic	3	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		10.00	20.00	30.00																								21.00																		10.00					10.00			10.00		1		
H4407	022	0	1	02	01	H4407_022_0	7	1	Preferred Generic	1	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					3.00	6.00	9.00																								0.00																		3.00					3.00							
H4407	022	0	1	02	01	H4407_022_0	7	3	Preferred Brand	1	4	000001	1	2	111100000010001000000001	30	60	90							2			90							30				31	14		45.00	90.00	135.00																								125.00																		45.00								45.00				
H4407	022	0	1	02	01	H4407_022_0	7	4	Non-Preferred Brand	1	4	100100	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		80.00	160.00	240.00																								230.00																		80.00					80.00			80.00				
H4407	022	0	1	02	01	H4407_022_0	7	5	Specialty Tier	1	4	010010	1	1	111100000010001000000101	30	60	90							2			90							30		31		31	14					317.45	33	33	33																							33																	33				33			33			
H4407	022	0	1	02	01	H4407_022_0	7	1	Preferred Generic	3	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					3.00	6.00	9.00																								0.00																		3.00					3.00					1		
H4407	023	0	1	02	01	H4407_023_0	8	1	Preferred Generic	1	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					3.00	6.00	9.00																								0.00																		3.00					3.00							
H4407	023	0	1	02	01	H4407_023_0	8	2	Non-Preferred Generic	1	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		6.00	12.00	18.00																								9.00																		6.00					6.00			6.00				
H4407	023	0	1	02	01	H4407_023_0	8	4	Non-Preferred Brand	1	4	100100	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		85.00	170.00	255.00																								245.00																		85.00					85.00			85.00				
H4407	023	0	1	02	01	H4407_023_0	8	3	Preferred Brand	1	4	000001	1	2	111100000010001000000001	30	60	90							2			90							30				31	14		45.00	90.00	135.00																								125.00																		45.00								45.00				
H4407	023	0	1	02	01	H4407_023_0	8	2	Non-Preferred Generic	3	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		6.00	12.00	18.00																								9.00																		6.00					6.00			6.00		2	2	
H4407	023	0	1	02	01	H4407_023_0	8	1	Preferred Generic	3	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					3.00	6.00	9.00																								0.00																		3.00					3.00					1		
H4407	023	0	1	02	01	H4407_023_0	8	5	Specialty Tier	1	4	010010	1	1	111100000010001000000101	30	60	90							2			90							30		31		31	14					318.94	33	33	33																							33																	33				33			33			
H4408	001	0	1	04	01	H4408_001_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					966.00	33																														33							33					33				33			33	2	3	
H4408	001	0	1	04	01	H4408_001_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H4408	001	0	1	04	01	H4408_001_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H4408	001	0	1	04	01	H4408_001_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H4408	001	0	1	04	01	H4408_001_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H4408	001	0	1	04	01	H4408_001_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H4408	001	0	1	04	01	H4408_001_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H4408	001	0	1	04	01	H4408_001_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H4408	001	0	1	04	01	H4408_001_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H4408	001	0	1	04	01	H4408_001_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					859.00	33																														33							33					33				33			33			
H4408	002	0	1	04	01	H4408_002_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H4408	002	0	1	04	01	H4408_002_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H4408	002	0	1	04	01	H4408_002_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					807.00	33																														33							33					33				33			33			
H4408	002	0	1	04	01	H4408_002_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H4408	002	0	1	04	01	H4408_002_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H4408	002	0	1	04	01	H4408_002_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H4408	002	0	1	04	01	H4408_002_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H4408	002	0	1	04	01	H4408_002_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1060.00	33																														33							33					33				33			33	2	3	
H4408	002	0	1	04	01	H4408_002_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H4408	002	0	1	04	01	H4408_002_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H4408	006	0	1	04	01	H4408_006_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H4408	006	0	1	04	01	H4408_006_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H4408	006	0	1	04	01	H4408_006_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H4408	006	0	1	04	01	H4408_006_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H4408	006	0	1	04	01	H4408_006_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1107.00	33																														33							33					33				33			33	2	3	
H4408	006	0	1	04	01	H4408_006_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H4408	006	0	1	04	01	H4408_006_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H4408	006	0	1	04	01	H4408_006_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H4408	006	0	1	04	01	H4408_006_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H4408	006	0	1	04	01	H4408_006_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					977.00	33																														33							33					33				33			33			
H4408	007	0	1	04	01	H4408_007_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H4408	007	0	1	04	01	H4408_007_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H4408	007	0	1	04	01	H4408_007_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H4408	007	0	1	04	01	H4408_007_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					814.00	33																														33							33					33				33			33			
H4408	007	0	1	04	01	H4408_007_0	4	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H4408	007	0	1	04	01	H4408_007_0	4	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H4408	007	0	1	04	01	H4408_007_0	4	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H4408	007	0	1	04	01	H4408_007_0	4	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H4408	007	0	1	04	01	H4408_007_0	4	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					890.00	33																														33							33					33				33			33	2	3	
H4408	007	0	1	04	01	H4408_007_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H4408	008	0	1	04	01	H4408_008_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H4408	008	0	1	04	01	H4408_008_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H4408	008	0	1	04	01	H4408_008_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H4408	008	0	1	04	01	H4408_008_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H4408	008	0	1	04	01	H4408_008_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					835.00	33																														33							33					33				33			33	2	3	
H4408	008	0	1	04	01	H4408_008_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H4408	008	0	1	04	01	H4408_008_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H4408	008	0	1	04	01	H4408_008_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H4408	008	0	1	04	01	H4408_008_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H4408	008	0	1	04	01	H4408_008_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					766.00	33																														33							33					33				33			33			
H4454	002	0	1	01	01	H4454_002_0	6	2	Non-Preferred Generic	1	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		10.00	20.00	30.00																								21.00																		10.00					10.00			10.00				
H4454	002	0	1	01	01	H4454_002_0	6	3	Preferred Brand	1	4	000001	1	2	111100000010001000000001	30	60	90							2			90							30				31	14		45.00	90.00	135.00																								125.00																		45.00								45.00				
H4454	002	0	1	01	01	H4454_002_0	6	4	Non-Preferred Brand	1	4	100100	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		80.00	160.00	240.00																								230.00																		80.00					80.00			80.00				
H4454	002	0	1	01	01	H4454_002_0	6	5	Specialty Tier	1	4	010010	1	1	111100000010001000000101	30	60	90							2			90							30		31		31	14					304.43	33	33	33																							33																	33				33			33			
H4454	002	0	1	01	01	H4454_002_0	6	1	Preferred Generic	3	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					3.00	6.00	9.00																								0.00																		3.00					3.00					1		
H4454	002	0	1	01	01	H4454_002_0	6	2	Non-Preferred Generic	3	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		10.00	20.00	30.00																								21.00																		10.00					10.00			10.00		1		
H4454	002	0	1	01	01	H4454_002_0	6	1	Preferred Generic	1	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					3.00	6.00	9.00																								0.00																		3.00					3.00							
H4454	030	0	1	02	01	H4454_030_0	6	1	Preferred Generic	1	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					3.00	6.00	9.00																								0.00																		3.00					3.00							
H4454	030	0	1	02	01	H4454_030_0	6	2	Non-Preferred Generic	1	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		10.00	20.00	30.00																								21.00																		10.00					10.00			10.00				
H4454	030	0	1	02	01	H4454_030_0	6	3	Preferred Brand	1	4	000001	1	2	111100000010001000000001	30	60	90							2			90							30				31	14		45.00	90.00	135.00																								125.00																		45.00								45.00				
H4454	030	0	1	02	01	H4454_030_0	6	4	Non-Preferred Brand	1	4	100100	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		80.00	160.00	240.00																								230.00																		80.00					80.00			80.00				
H4454	030	0	1	02	01	H4454_030_0	6	5	Specialty Tier	1	4	010010	1	1	111100000010001000000101	30	60	90							2			90							30		31		31	14					317.45	33	33	33																							33																	33				33			33			
H4454	030	0	1	02	01	H4454_030_0	6	1	Preferred Generic	3	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					3.00	6.00	9.00																								0.00																		3.00					3.00					1		
H4454	030	0	1	02	01	H4454_030_0	6	2	Non-Preferred Generic	3	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		10.00	20.00	30.00																								21.00																		10.00					10.00			10.00		1		
H4454	031	0	1	01	01	H4454_031_0	6	2	Non-Preferred Generic	3	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		12.00	24.00	36.00																								27.00																		12.00					12.00			12.00		1		
H4454	031	0	1	01	01	H4454_031_0	6	1	Preferred Generic	3	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					5.00	10.00	15.00																								6.00																		5.00					5.00					1		
H4454	031	0	1	01	01	H4454_031_0	6	5	Specialty Tier	1	4	010010	1	1	111100000010001000000101	30	60	90							2			90							30		31		31	14					304.43	33	33	33																							33																	33				33			33			
H4454	031	0	1	01	01	H4454_031_0	6	4	Non-Preferred Brand	1	4	100100	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		80.00	160.00	240.00																								230.00																		80.00					80.00			80.00				
H4454	031	0	1	01	01	H4454_031_0	6	3	Preferred Brand	1	4	000001	1	2	111100000010001000000001	30	60	90							2			90							30				31	14		45.00	90.00	135.00																								125.00																		45.00								45.00				
H4454	031	0	1	01	01	H4454_031_0	6	1	Preferred Generic	1	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					5.00	10.00	15.00																								6.00																		5.00					5.00							
H4454	031	0	1	01	01	H4454_031_0	6	2	Non-Preferred Generic	1	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		12.00	24.00	36.00																								27.00																		12.00					12.00			12.00				
H4454	032	0	1	02	01	H4454_032_0	6	1	Preferred Generic	3	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					3.00	6.00	9.00																								0.00																		3.00					3.00					1		
H4454	032	0	1	02	01	H4454_032_0	6	1	Preferred Generic	1	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					3.00	6.00	9.00																								0.00																		3.00					3.00							
H4454	032	0	1	02	01	H4454_032_0	6	2	Non-Preferred Generic	1	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		10.00	20.00	30.00																								21.00																		10.00					10.00			10.00				
H4454	032	0	1	02	01	H4454_032_0	6	3	Preferred Brand	1	4	000001	1	2	111100000010001000000001	30	60	90							2			90							30				31	14		45.00	90.00	135.00																								125.00																		45.00								45.00				
H4454	032	0	1	02	01	H4454_032_0	6	4	Non-Preferred Brand	1	4	100100	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		80.00	160.00	240.00																								230.00																		80.00					80.00			80.00				
H4454	032	0	1	02	01	H4454_032_0	6	2	Non-Preferred Generic	3	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		10.00	20.00	30.00																								21.00																		10.00					10.00			10.00		1		
H4454	032	0	1	02	01	H4454_032_0	6	5	Specialty Tier	1	4	010010	1	1	111100000010001000000101	30	60	90							2			90							30		31		31	14					304.43	33	33	33																							33																	33				33			33			
H4456	010	0	1	01	01	H4456_010_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H4456	010	0	1	01	01	H4456_010_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H4456	010	0	1	01	01	H4456_010_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					7.00		21.00																															14.00							21.00				7.00					7.00							
H4456	010	0	1	01	01	H4456_010_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					4.00		12.00																															8.00							12.00				4.00					4.00							
H4456	010	0	1	01	01	H4456_010_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					434.00	33		33																														33							33			33				33			33			
H4456	013	0	1	02	01	H4456_013_0	8	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					496.00	33		33																														33							33			33				33			33			
H4456	013	0	1	02	01	H4456_013_0	8	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H4456	013	0	1	02	01	H4456_013_0	8	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H4456	013	0	1	02	01	H4456_013_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					4.00		12.00																															8.00							12.00				4.00					4.00							
H4456	013	0	1	02	01	H4456_013_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					7.00		21.00																															14.00							21.00				7.00					7.00							
H4456	015	0	1	01	01	H4456_015_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		85.00		255.00																															245.00							255.00				85.00					85.00			85.00				
H4456	015	0	1	01	01	H4456_015_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		38.00		114.00																															104.00							114.00				38.00					38.00			38.00				
H4456	015	0	1	01	01	H4456_015_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H4456	015	0	1	01	01	H4456_015_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H4456	015	0	1	01	01	H4456_015_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					400.00	33		33																														33							33			33				33			33			
H4456	021	0	1	01	01	H4456_021_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					543.00	33		33																														33							33			33				33			33			
H4456	021	0	1	01	01	H4456_021_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		91.00		273.00																															263.00							273.00				91.00					91.00			91.00				
H4456	021	0	1	01	01	H4456_021_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		44.00		132.00																															122.00							132.00				44.00					44.00			44.00				
H4456	021	0	1	01	01	H4456_021_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															0.00							9.00				3.00					3.00							
H4456	021	0	1	01	01	H4456_021_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															0.00							18.00				6.00					6.00							
H4456	025	0	1	01	01	H4456_025_0	7	4	Non-Preferred Brand	1	3	100100		2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H4456	025	0	1	01	01	H4456_025_0	7	3	Preferred Brand	1	3	010001		2	110100000010000001001101	31		90							1						90			90	31		31		31	14		44.00		132.00																															122.00							132.00				44.00					44.00			44.00				
H4456	025	0	1	01	01	H4456_025_0	7	2	Non-Preferred Generic	1	3	000100		2	010100000010000001001100	31		90							1						90			90	31		31					7.00		21.00																															14.00							21.00				7.00					7.00							
H4456	025	0	1	01	01	H4456_025_0	7	1	Preferred Generic	1	3	001000		2	010100000010000001001100	31		90							1						90			90	31		31					4.00		12.00																															8.00							12.00				4.00					4.00							
H4456	025	0	1	01	01	H4456_025_0	7	5	Specialty Tier	1	3	010010		1	110100000010000001001101	31		90							1						90			90	31		31		31	14					451.00	33		33																														33							33			33				33			33			
H4461	001	0	1	01	01	H4461_001_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00		2	3	
H4461	001	0	1	01	01	H4461_001_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00		2	2	
H4461	001	0	1	01	01	H4461_001_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H4461	001	0	1	01	01	H4461_001_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H4461	001	0	1	01	01	H4461_001_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1144.00	33																														33							33					33				33			33	2	3	
H4461	001	0	1	01	01	H4461_001_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H4461	001	0	1	01	01	H4461_001_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H4461	001	0	1	01	01	H4461_001_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00				
H4461	001	0	1	01	01	H4461_001_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00				
H4461	001	0	1	01	01	H4461_001_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					921.00	33																														33							33					33				33			33			
H4461	015	0	1	01	01	H4461_015_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H4461	015	0	1	01	01	H4461_015_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H4461	015	0	1	01	01	H4461_015_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H4461	015	0	1	01	01	H4461_015_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H4461	015	0	1	01	01	H4461_015_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					780.00	33																														33							33					33				33			33			
H4461	015	0	1	01	01	H4461_015_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					849.00	33																														33							33					33				33			33	2	3	
H4461	015	0	1	01	01	H4461_015_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H4461	015	0	1	01	01	H4461_015_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H4461	015	0	1	01	01	H4461_015_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H4461	015	0	1	01	01	H4461_015_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H4461	018	0	1	01	01	H4461_018_0	9	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H4461	018	0	1	01	01	H4461_018_0	9	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H4461	018	0	1	01	01	H4461_018_0	9	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H4461	018	0	1	01	01	H4461_018_0	9	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	
H4461	018	0	1	01	01	H4461_018_0	9	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					716.00	33																														33							33					33				33			33	2	3	
H4461	018	0	1	01	01	H4461_018_0	9	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H4461	018	0	1	01	01	H4461_018_0	9	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H4461	018	0	1	01	01	H4461_018_0	9	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H4461	018	0	1	01	01	H4461_018_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					651.00	33																														33							33					33				33			33			
H4461	018	0	1	01	01	H4461_018_0	9	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H4461	022	0	1	01	01	H4461_022_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H4461	022	0	1	01	01	H4461_022_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H4461	022	0	1	01	01	H4461_022_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H4461	022	0	1	01	01	H4461_022_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		91.00		273.00																													91.00		263.00					91.00		273.00				91.00					91.00			91.00				
H4461	022	0	1	01	01	H4461_022_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					716.00	25																														25							25					25				25			25			
H4461	025	0	1	01	01	H4461_025_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		3.00		9.00																													0.00		0.00					3.00		9.00				3.00					3.00			3.00				
H4461	025	0	1	01	01	H4461_025_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H4461	025	0	1	01	01	H4461_025_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					887.00	33																														33							33					33				33			33	2	3	
H4461	025	0	1	01	01	H4461_025_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H4461	025	0	1	01	01	H4461_025_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H4461	025	0	1	01	01	H4461_025_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H4461	025	0	1	01	01	H4461_025_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		3.00		9.00																													0.00		0.00					3.00		9.00				3.00					3.00			3.00		2	3	1
H4461	025	0	1	01	01	H4461_025_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					773.00	33																														33							33					33				33			33			
H4461	025	0	1	01	01	H4461_025_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H4461	025	0	1	01	01	H4461_025_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H4461	029	0	1	01	01	H4461_029_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		2.00		6.00																													0.00		0.00					2.00		6.00				2.00					2.00			2.00				
H4461	029	0	1	01	01	H4461_029_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H4461	029	0	1	01	01	H4461_029_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H4461	029	0	1	01	01	H4461_029_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H4461	029	0	1	01	01	H4461_029_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					884.00	33																														33							33					33				33			33	2	3	
H4461	029	0	1	01	01	H4461_029_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					773.00	33																														33							33					33				33			33			
H4461	029	0	1	01	01	H4461_029_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H4461	029	0	1	01	01	H4461_029_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H4461	029	0	1	01	01	H4461_029_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H4461	029	0	1	01	01	H4461_029_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		2.00		6.00																													0.00		0.00					2.00		6.00				2.00					2.00			2.00		2	3	
H4506	003	0	1	01	01	H4506_003_0	5	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00							
H4506	003	0	1	01	01	H4506_003_0	5	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H4506	003	0	1	01	01	H4506_003_0	5	3	Preferred Brand	3	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		40.00		100.00																													40.00		80.00					40.00		100.00				40.00								40.00		2		
H4506	003	0	1	01	01	H4506_003_0	5	2	Non-Preferred Generic	3	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H4506	003	0	1	01	01	H4506_003_0	5	1	Preferred Generic	3	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00					1		
H4506	003	0	1	01	01	H4506_003_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					500.00	33																														33							33					33				33			33			
H4506	003	0	1	01	01	H4506_003_0	5	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		80.00		200.00																													80.00		160.00					80.00		200.00				80.00								80.00				
H4506	003	0	1	01	01	H4506_003_0	5	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		40.00		100.00																													40.00		80.00					40.00		100.00				40.00								40.00				
H4506	027	0	1	01	01	H4506_027_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00							
H4506	027	0	1	01	01	H4506_027_0	6	2	Non-Preferred Generic	3	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		1		
H4506	027	0	1	01	01	H4506_027_0	6	1	Preferred Generic	3	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00					1		
H4506	027	0	1	01	01	H4506_027_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					500.00	33																														33							33					33				33			33			
H4506	027	0	1	01	01	H4506_027_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		80.00		200.00																													80.00		160.00					80.00		200.00				80.00								80.00				
H4506	027	0	1	01	01	H4506_027_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		40.00		100.00																													40.00		80.00					40.00		100.00				40.00								40.00				
H4506	027	0	1	01	01	H4506_027_0	6	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H4506	027	0	1	01	01	H4506_027_0	6	3	Preferred Brand	3	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		40.00		100.00																													40.00		80.00					40.00		100.00				40.00								40.00		2		
H4510	012	0	1	01	01	H4510_012_0	8	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		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	8	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		20.00		60.00																													20.00		50.00					20.00		60.00				20.00					20.00			20.00				
H4510	012	0	1	01	01	H4510_012_0	8	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		60.00		180.00																													60.00		170.00					60.00		180.00				60.00					60.00			60.00				
H4510	012	0	1	01	01	H4510_012_0	8	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					812.00	33																														33							33					33				33			33			
H4510	012	0	1	01	01	H4510_012_0	8	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	1
H4510	012	0	1	01	01	H4510_012_0	8	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		20.00		60.00																													20.00		50.00					20.00		60.00				20.00					20.00			20.00		2	3	
H4510	012	0	1	01	01	H4510_012_0	8	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					857.00	33																														33							33					33				33			33	2	3	
H4510	012	0	1	01	01	H4510_012_0	8	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		60.00		180.00																													60.00		170.00					60.00		180.00				60.00					60.00			60.00		2	3	
H4510	015	0	1	01	01	H4510_015_0	8	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		60.00		180.00																													60.00		170.00					60.00		180.00				60.00					60.00			60.00		2	3	
H4510	015	0	1	01	01	H4510_015_0	8	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					738.00	33																														33							33					33				33			33	2	3	
H4510	015	0	1	01	01	H4510_015_0	8	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		20.00		60.00																													20.00		50.00					20.00		60.00				20.00					20.00			20.00		2	3	
H4510	015	0	1	01	01	H4510_015_0	8	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	1
H4510	015	0	1	01	01	H4510_015_0	8	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					721.00	33																														33							33					33				33			33			
H4510	015	0	1	01	01	H4510_015_0	8	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		60.00		180.00																													60.00		170.00					60.00		180.00				60.00					60.00			60.00				
H4510	015	0	1	01	01	H4510_015_0	8	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		20.00		60.00																													20.00		50.00					20.00		60.00				20.00					20.00			20.00				
H4510	015	0	1	01	01	H4510_015_0	8	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		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	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					773.00	30																														30							30					30				30			30	2	3	
H4510	018	0	1	01	01	H4510_018_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00		2	3	
H4510	018	0	1	01	01	H4510_018_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H4510	018	0	1	01	01	H4510_018_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H4510	018	0	1	01	01	H4510_018_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H4510	018	0	1	01	01	H4510_018_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					709.00	30																														30							30					30				30			30			
H4510	018	0	1	01	01	H4510_018_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00				
H4510	018	0	1	01	01	H4510_018_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H4510	018	0	1	01	01	H4510_018_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H4510	018	0	1	01	01	H4510_018_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00		2	3	1
H4510	022	0	1	01	01	H4510_022_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					673.00	33																														33							33					33				33			33	2	3	
H4510	022	0	1	01	01	H4510_022_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H4510	022	0	1	01	01	H4510_022_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H4510	022	0	1	01	01	H4510_022_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H4510	022	0	1	01	01	H4510_022_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H4510	022	0	1	01	01	H4510_022_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					626.00	33																														33							33					33				33			33			
H4510	022	0	1	01	01	H4510_022_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H4510	022	0	1	01	01	H4510_022_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H4510	022	0	1	01	01	H4510_022_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H4510	022	0	1	01	01	H4510_022_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H4510	027	0	1	01	01	H4510_027_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H4510	027	0	1	01	01	H4510_027_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H4510	027	0	1	01	01	H4510_027_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					553.00	33																														33							33					33				33			33	2	3	
H4510	027	0	1	01	01	H4510_027_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00		2	3	
H4510	027	0	1	01	01	H4510_027_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		42.00		126.00																													42.00		116.00					42.00		126.00				42.00					42.00			42.00				
H4510	027	0	1	01	01	H4510_027_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H4510	027	0	1	01	01	H4510_027_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H4510	027	0	1	01	01	H4510_027_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					494.00	33																														33							33					33				33			33			
H4510	027	0	1	01	01	H4510_027_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00				
H4510	027	0	1	01	01	H4510_027_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		42.00		126.00																													42.00		116.00					42.00		126.00				42.00					42.00			42.00		2	2	
H4510	028	0	1	01	01	H4510_028_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00				
H4510	028	0	1	01	01	H4510_028_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					775.00	33																														33							33					33				33			33			
H4510	028	0	1	01	01	H4510_028_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H4510	028	0	1	01	01	H4510_028_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H4510	028	0	1	01	01	H4510_028_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H4510	028	0	1	01	01	H4510_028_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00		2	3	
H4510	028	0	1	01	01	H4510_028_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					897.00	33																														33							33					33				33			33	2	3	
H4510	028	0	1	01	01	H4510_028_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H4510	028	0	1	01	01	H4510_028_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H4510	028	0	1	01	01	H4510_028_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H4510	029	0	1	01	01	H4510_029_0	5	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					797.00	33																														33							33					33				33			33			
H4510	029	0	1	01	01	H4510_029_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H4510	029	0	1	01	01	H4510_029_0	5	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	3	
H4510	029	0	1	01	01	H4510_029_0	5	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H4510	029	0	1	01	01	H4510_029_0	5	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H4510	029	0	1	01	01	H4510_029_0	5	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H4510	029	0	1	01	01	H4510_029_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H4510	029	0	1	01	01	H4510_029_0	5	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					926.00	33																														33							33					33				33			33	2	3	
H4510	030	0	1	01	01	H4510_030_0	5	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					981.00	33																														33							33					33				33			33	2	3	
H4510	030	0	1	01	01	H4510_030_0	5	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H4510	030	0	1	01	01	H4510_030_0	5	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	3	
H4510	030	0	1	01	01	H4510_030_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H4510	030	0	1	01	01	H4510_030_0	5	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					842.00	33																														33							33					33				33			33			
H4510	030	0	1	01	01	H4510_030_0	5	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H4510	030	0	1	01	01	H4510_030_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H4510	030	0	1	01	01	H4510_030_0	5	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H4513	001	0	1	01	01	H4513_001_0	7	1	Preferred Generic	1	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					0.00	0.00	0.00																								0.00																		0.00					0.00							
H4513	001	0	1	01	01	H4513_001_0	7	2	Non-Preferred Generic	1	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		4.00	8.00	12.00																								3.00																		4.00					4.00			4.00				
H4513	001	0	1	01	01	H4513_001_0	7	3	Preferred Brand	1	4	000001	1	2	111100000010001000000001	30	60	90							2			90							30				31	14		30.00	60.00	90.00																								80.00																		30.00								30.00				
H4513	001	0	1	01	01	H4513_001_0	7	4	Non-Preferred Brand	1	4	100100	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		60.00	120.00	180.00																								170.00																		60.00					60.00			60.00				
H4513	001	0	1	01	01	H4513_001_0	7	5	Specialty Tier	1	4	010010	1	1	111100000010001000000101	30	60	90							2			90							30		31		31	14					298.97	33	33	33																							33																	33				33			33			
H4513	001	0	1	01	01	H4513_001_0	7	1	Preferred Generic	3	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					0.00	0.00	0.00																								0.00																		0.00					0.00					1		
H4513	001	0	1	01	01	H4513_001_0	7	2	Non-Preferred Generic	3	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		4.00	8.00	12.00																								3.00																		4.00					4.00			4.00		1		
H4514	007	0	1	02	01	H4514_007_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H4514	007	0	1	02	01	H4514_007_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H4514	007	0	1	02	01	H4514_007_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H4514	007	0	1	02	01	H4514_007_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H4514	007	0	1	02	01	H4514_007_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					495.00	33		33																														33							33			33				33			33			
H4520	006	0	1	04	01	H4520_006_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					881.00	33																														33							33					33				33			33	2	3	
H4520	006	0	1	04	01	H4520_006_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		83.00		249.00																													83.00		239.00					83.00		249.00				83.00					83.00			83.00		2	3	
H4520	006	0	1	04	01	H4520_006_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		42.00		126.00																													42.00		116.00					42.00		126.00				42.00					42.00			42.00		2	2	
H4520	006	0	1	04	01	H4520_006_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H4520	006	0	1	04	01	H4520_006_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		83.00		249.00																													83.00		239.00					83.00		249.00				83.00					83.00			83.00				
H4520	006	0	1	04	01	H4520_006_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					784.00	33																														33							33					33				33			33			
H4520	006	0	1	04	01	H4520_006_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H4520	006	0	1	04	01	H4520_006_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H4520	006	0	1	04	01	H4520_006_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		42.00		126.00																													42.00		116.00					42.00		126.00				42.00					42.00			42.00				
H4520	006	0	1	04	01	H4520_006_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00		2	3	1
H4522	001	0	1	04	01	H4522_001_0	7	1	Preferred Generic	3	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00					1		
H4522	001	0	1	04	01	H4522_001_0	7	2	Non-Preferred Generic	3	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00					1		
H4522	001	0	1	04	01	H4522_001_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					563.00	33		33																														33							33			33				33			33			
H4522	001	0	1	04	01	H4522_001_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H4522	001	0	1	04	01	H4522_001_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H4522	001	0	1	04	01	H4522_001_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H4522	001	0	1	04	01	H4522_001_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H4523	001	0	1	01	01	H4523_001_0	6	1	Preferred Generic	3	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					7.00	14.00	21.00																													7.00	14.00	14.00					7.00	14.00	21.00					7.00				7.00					1		
H4523	001	0	1	01	01	H4523_001_0	6	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					557.20	33	33	33																												33	33	33					33	33	33				33			33			33			
H4523	001	0	1	01	01	H4523_001_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H4523	001	0	1	01	01	H4523_001_0	6	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H4523	001	0	1	01	01	H4523_001_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H4523	001	0	1	01	01	H4523_001_0	6	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					7.00	14.00	21.00																													7.00	14.00	14.00					7.00	14.00	21.00					7.00				7.00							
H4523	005	0	1	01	01	H4523_005_0	6	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					7.00	14.00	21.00																													7.00	14.00	14.00					7.00	14.00	21.00					7.00				7.00							
H4523	005	0	1	01	01	H4523_005_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H4523	005	0	1	01	01	H4523_005_0	6	1	Preferred Generic	3	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					7.00	14.00	21.00																													7.00	14.00	14.00					7.00	14.00	21.00					7.00				7.00					1		
H4523	005	0	1	01	01	H4523_005_0	6	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					379.37	33	33	33																												33	33	33					33	33	33				33			33			33			
H4523	005	0	1	01	01	H4523_005_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H4523	005	0	1	01	01	H4523_005_0	6	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H4523	015	0	1	01	01	H4523_015_0	6	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					191.40	33	33	33																												33	33	33					33	33	33				33			33			33			
H4523	015	0	1	01	01	H4523_015_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H4523	015	0	1	01	01	H4523_015_0	6	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H4523	015	0	1	01	01	H4523_015_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H4523	015	0	1	01	01	H4523_015_0	6	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					7.00	14.00	21.00																													7.00	14.00	14.00					7.00	14.00	21.00					7.00				7.00							
H4523	015	0	1	01	01	H4523_015_0	6	1	Preferred Generic	3	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					7.00	14.00	21.00																													7.00	14.00	14.00					7.00	14.00	21.00					7.00				7.00					1		
H4524	001	0	1	04	01	H4524_001_0	8	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					7.00	14.00	21.00																													7.00	14.00	14.00					7.00	14.00	21.00					7.00				7.00							
H4524	001	0	1	04	01	H4524_001_0	8	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					307.34	33	33	33																												33	33	33					33	33	33				33			33			33			
H4524	001	0	1	04	01	H4524_001_0	8	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H4524	001	0	1	04	01	H4524_001_0	8	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H4524	001	0	1	04	01	H4524_001_0	8	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H4524	007	0	1	04	01	H4524_007_0	8	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					7.00	14.00	21.00																													7.00	14.00	14.00					7.00	14.00	21.00					7.00				7.00							
H4524	007	0	1	04	01	H4524_007_0	8	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H4524	007	0	1	04	01	H4524_007_0	8	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H4524	007	0	1	04	01	H4524_007_0	8	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H4524	007	0	1	04	01	H4524_007_0	8	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					224.69	33	33	33																												33	33	33					33	33	33				33			33			33			
H4524	013	0	1	04	01	H4524_013_0	6	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					182.57	33	33	33																												33	33	33					33	33	33				33			33			33			
H4524	013	0	1	04	01	H4524_013_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H4524	013	0	1	04	01	H4524_013_0	6	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H4524	013	0	1	04	01	H4524_013_0	6	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					7.00	14.00	21.00																													7.00	14.00	14.00					7.00	14.00	21.00					7.00				7.00							
H4524	013	0	1	04	01	H4524_013_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H4525	001	0	1	01	01	H4525_001_0	5	2	Preferred Brand	1	4	000001	1	2	111100000001111000000001	31	62	90							2	31	62	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	112.50																			45.00							45.00				
H4525	001	0	1	01	01	H4525_001_0	5	1	Preferred Generic	1	4	001000	1	2	011100000001111000000110	31	62	90							2	31	62	90								10	31	14				7.00	14.00	21.00																						7.00	14.00	17.50																			7.00				7.00							
H4525	001	0	1	01	01	H4525_001_0	5	3	Specialty Tier	1	4	100000	1	1	111100000001111000000001	31	62	90							2	31	62	90								10			31	14					627.00	33	33	33																					33	33	33																		33						33			
H4525	002	0	1	01	01	H4525_002_0	5	1	Preferred Generic	1	4	001000	1	2	011100000001111000000110	31	62	90							2	31	62	90								10	31	14				7.00	14.00	21.00																						7.00	14.00	17.50																			7.00				7.00							
H4525	002	0	1	01	01	H4525_002_0	5	2	Preferred Brand	1	4	000001	1	2	111100000001111000000001	31	62	90							2	31	62	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	112.50																			45.00							45.00				
H4525	002	0	1	01	01	H4525_002_0	5	3	Specialty Tier	1	4	100000	1	1	111100000001111000000001	31	62	90							2	31	62	90								10			31	14					627.00	33	33	33																					33	33	33																		33						33			
H4525	008	0	1	01	01	H4525_008_0	4	1	Preferred Generic	3	4	001000	1	2	011100000001111000000110	31	62	90							2	31	62	90								10	31	14				5.00	10.00	15.00																						5.00	10.00	12.50																			5.00				5.00					1		
H4525	008	0	1	01	01	H4525_008_0	4	3	Specialty Tier	1	4	100000	1	1	111100000001111000000001	31	62	90							2	31	62	90								10			31	14					627.00	33	33	33																					33	33	33																		33						33			
H4525	008	0	1	01	01	H4525_008_0	4	2	Preferred Brand	1	4	000001	1	2	111100000001111000000001	31	62	90							2	31	62	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	112.50																			45.00							45.00				
H4525	008	0	1	01	01	H4525_008_0	4	1	Preferred Generic	1	4	001000	1	2	011100000001111000000110	31	62	90							2	31	62	90								10	31	14				5.00	10.00	15.00																						5.00	10.00	12.50																			5.00				5.00							
H4525	009	0	1	01	01	H4525_009_0	6	1	Preferred Generic	3	4	001000	1	2	011100000001111000000110	31	62	90							2	31	62	90								10	31	14				5.00	10.00	15.00																						5.00	10.00	12.50																			5.00				5.00					1		
H4525	009	0	1	01	01	H4525_009_0	6	3	Specialty Tier	1	4	100000	1	1	111100000001111000000001	31	62	90							2	31	62	90								10			31	14					627.00	33	33	33																					33	33	33																		33						33			
H4525	009	0	1	01	01	H4525_009_0	6	2	Preferred Brand	1	4	000001	1	2	111100000001111000000001	31	62	90							2	31	62	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	112.50																			45.00							45.00				
H4525	009	0	1	01	01	H4525_009_0	6	1	Preferred Generic	1	4	001000	1	2	011100000001111000000110	31	62	90							2	31	62	90								10	31	14				5.00	10.00	15.00																						5.00	10.00	12.50																			5.00				5.00							
H4527	001	0	1	01	01	H4527_001_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		25.00		75.00																															65.00							75.00				25.00					25.00			25.00				
H4527	001	0	1	01	01	H4527_001_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															2.00							9.00				3.00					3.00							
H4527	001	0	1	01	01	H4527_001_0	7	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		20.00		60.00																															5.00							60.00				20.00					20.00			20.00				
H4527	001	0	1	01	01	H4527_001_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		80.00		240.00																															230.00							240.00				80.00					80.00			80.00				
H4527	001	0	1	01	01	H4527_001_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					841.00	33		33																														33							33			33				33			33			
H4527	001	0	1	01	01	H4527_001_0	7	1	Preferred Generic	3	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															2.00							9.00				3.00					3.00					1		
H4527	002	0	1	01	01	H4527_002_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															2.00							9.00				3.00					3.00							
H4527	002	0	1	01	01	H4527_002_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H4527	002	0	1	01	01	H4527_002_0	7	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		33.00		99.00																															5.00							99.00				33.00					33.00			33.00				
H4527	002	0	1	01	01	H4527_002_0	7	1	Preferred Generic	3	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															2.00							9.00				3.00					3.00					1		
H4527	002	0	1	01	01	H4527_002_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					703.00	33		33																														33							33			33				33			33			
H4527	002	0	1	01	01	H4527_002_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		90.00		270.00																															260.00							270.00				90.00					90.00			90.00				
H4527	005	0	1	01	01	H4527_005_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															2.00							9.00				3.00					3.00							
H4527	005	0	1	01	01	H4527_005_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		90.00		270.00																															260.00							270.00				90.00					90.00			90.00				
H4527	005	0	1	01	01	H4527_005_0	7	1	Preferred Generic	3	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															2.00							9.00				3.00					3.00					1		
H4527	005	0	1	01	01	H4527_005_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					655.00	33		33																														33							33			33				33			33			
H4527	005	0	1	01	01	H4527_005_0	7	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		33.00		99.00																															5.00							99.00				33.00					33.00			33.00				
H4527	005	0	1	01	01	H4527_005_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H4527	013	0	1	01	01	H4527_013_0	7	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		33.00		99.00																															5.00							99.00				33.00					33.00			33.00				
H4527	013	0	1	01	01	H4527_013_0	7	1	Preferred Generic	3	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															2.00							9.00				3.00					3.00					1		
H4527	013	0	1	01	01	H4527_013_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															2.00							9.00				3.00					3.00							
H4527	013	0	1	01	01	H4527_013_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		40.00		120.00																															110.00							120.00				40.00					40.00			40.00				
H4527	013	0	1	01	01	H4527_013_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		85.00		255.00																															245.00							255.00				85.00					85.00			85.00				
H4527	013	0	1	01	01	H4527_013_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					730.00	33		33																														33							33			33				33			33			
H4528	001	0	1	01	01	H4528_001_0	9	1	Preferred Generic	3	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					0.00	0.00	0.00																								0.00																		0.00					0.00					1		
H4528	001	0	1	01	01	H4528_001_0	9	5	Specialty Tier	1	4	010010	1	1	111100000010001000000101	30	60	90							2			90							30		31		31	14					308.81	33	33	33																							33																	33				33			33			
H4528	001	0	1	01	01	H4528_001_0	9	4	Non-Preferred Brand	1	4	100100	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		70.00	140.00	210.00																								200.00																		70.00					70.00			70.00				
H4528	001	0	1	01	01	H4528_001_0	9	2	Non-Preferred Generic	1	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		4.00	8.00	12.00																								3.00																		4.00					4.00			4.00				
H4528	001	0	1	01	01	H4528_001_0	9	3	Preferred Brand	1	4	000001	1	2	111100000010001000000001	30	60	90							2			90							30				31	14		35.00	70.00	105.00																								95.00																		35.00								35.00				
H4528	001	0	1	01	01	H4528_001_0	9	1	Preferred Generic	1	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					0.00	0.00	0.00																								0.00																		0.00					0.00							
H4528	001	0	1	01	01	H4528_001_0	9	2	Non-Preferred Generic	3	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		4.00	8.00	12.00																								3.00																		4.00					4.00			4.00		1		
H4528	014	0	1	01	01	H4528_014_0	8	6	Select Diabetic Drugs	1	4	010010	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		5.00	10.00	15.00																								5.00																		5.00					5.00			5.00				
H4528	014	0	1	01	01	H4528_014_0	8	1	Preferred Generic	1	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					3.00	6.00	9.00																								0.00																		3.00					3.00							
H4528	014	0	1	01	01	H4528_014_0	8	3	Preferred Brand	1	4	000001	1	2	111100000010001000000001	30	60	90							2			90							30				31	14		35.00	70.00	105.00																								95.00																		35.00								35.00				
H4528	014	0	1	01	01	H4528_014_0	8	4	Non-Preferred Brand	1	4	100100	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		70.00	140.00	210.00																								200.00																		70.00					70.00			70.00				
H4528	014	0	1	01	01	H4528_014_0	8	5	Specialty Tier	1	4	010010	1	1	111100000010001000000101	30	60	90							2			90							30		31		31	14					279.05	33	33	33																							33																	33				33			33			
H4528	014	0	1	01	01	H4528_014_0	8	2	Non-Preferred Generic	1	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		8.00	16.00	24.00																								15.00																		8.00					8.00			8.00				
H4529	014	0	1	01	01	H4529_014_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00		2	3	
H4529	014	0	1	01	01	H4529_014_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					2567.00	33																														33							33					33				33			33	2	3	
H4529	014	0	1	01	01	H4529_014_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H4529	014	0	1	01	01	H4529_014_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		11.00		33.00																													0.00		0.00					11.00		33.00				11.00					11.00			11.00				
H4529	014	0	1	01	01	H4529_014_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H4529	014	0	1	01	01	H4529_014_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00				
H4529	014	0	1	01	01	H4529_014_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					829.00	33																														33							33					33				33			33			
H4529	014	0	1	01	01	H4529_014_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00		2	3	1
H4529	014	0	1	01	01	H4529_014_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		11.00		33.00																													0.00		0.00					11.00		33.00				11.00					11.00			11.00		2	2	
H4529	014	0	1	01	01	H4529_014_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H4564	001	0	1	18	06	H4564_001_0	6	2	Preferred Brand	1	4	000001	1	2	111100000010101000000001	30	60	90							2	30		90							30				34	14		35.00	70.00	105.00																						35.00		70.00																		35.00								35.00				
H4564	001	0	1	18	06	H4564_001_0	6	3	Non-Preferred Brand	1	4	100000	1	2	111100000010101000000001	30	60	90							2	30		90							30				34	14		64.00	128.00	192.00																						64.00		128.00																		64.00								64.00				
H4564	001	0	1	18	06	H4564_001_0	6	4	Specialty Tier	1	4	010010	1	1	111100000010101000000111	30	60	90							2	30		90							30		34	14	34	14					354.00	33	33	33																					33		33																	33				33			33			
H4564	001	0	1	18	06	H4564_001_0	6	1	Preferred Generic	1	4	001000	1	2	011100000010101000000110	30	60	90							2	30		90							30		34	14				7.00	14.00	21.00																						7.00		14.00																		7.00					7.00							
H4564	002	0	1	18	06	H4564_002_0	6	1	Preferred Generic	1	4	001000	1	2	011100000010101000000110	30	60	90							2	30		90							30		34	14				7.00	14.00	21.00																						7.00		14.00																		7.00					7.00							
H4564	002	0	1	18	06	H4564_002_0	6	2	Preferred Brand	1	4	000001	1	2	111100000010101000000001	30	60	90							2	30		90							30				34	14		35.00	70.00	105.00																						35.00		70.00																		35.00								35.00				
H4564	002	0	1	18	06	H4564_002_0	6	3	Non-Preferred Brand	1	4	100000	1	2	111100000010101000000001	30	60	90							2	30		90							30				34	14		64.00	128.00	192.00																						64.00		128.00																		64.00								64.00				
H4564	002	0	1	18	06	H4564_002_0	6	4	Specialty Tier	1	4	010010	1	1	111100000010101000000111	30	60	90							2	30		90							30		34	14	34	14					354.00	33	33	33																					33		33																	33				33			33			
H4564	003	0	1	18	06	H4564_003_0	6	4	Specialty Tier	1	4	010010	1	1	111100000010101000000111	30	60	90							2	30		90							30		34	14	34	14					354.00	33	33	33																					33		33																	33				33			33			
H4564	003	0	1	18	06	H4564_003_0	6	1	Preferred Generic	1	4	001000	1	2	011100000010101000000110	30	60	90							2	30		90							30		34	14				7.00	14.00	21.00																						7.00		14.00																		7.00					7.00							
H4564	003	0	1	18	06	H4564_003_0	6	2	Preferred Brand	1	4	000001	1	2	111100000010101000000001	30	60	90							2	30		90							30				34	14		35.00	70.00	105.00																						35.00		70.00																		35.00								35.00				
H4564	003	0	1	18	06	H4564_003_0	6	3	Non-Preferred Brand	1	4	100000	1	2	111100000010101000000001	30	60	90							2	30		90							30				34	14		64.00	128.00	192.00																						64.00		128.00																		64.00								64.00				
H4564	004	0	1	18	06	H4564_004_0	6	1	Preferred Generic	1	4	001000	1	2	011100000010101000000110	30	60	90							2	30		90							30		34	14				2.00	4.00	6.00																						2.00		4.00																		2.00					2.00							
H4564	004	0	1	18	06	H4564_004_0	6	3	Non-Preferred Brand	1	4	100000	1	2	111100000010101000000001	30	60	90							2	30		90							30				34	14		65.00	130.00	195.00																						65.00		130.00																		65.00								65.00				
H4564	004	0	1	18	06	H4564_004_0	6	1	Preferred Generic	3	4	001000	1	2	011100000010101000000110	30	60	90							2	30		90							30		34	14				4.00	8.00	12.00																						4.00		8.00																		4.00					4.00					1		
H4564	004	0	1	18	06	H4564_004_0	6	4	Specialty Tier	1	4	010010	1	1	111100000010101000000111	30	60	90							2	30		90							30		34	14	34	14					354.00	33	33	33																					33		33																	33				33			33			
H4564	004	0	1	18	06	H4564_004_0	6	2	Preferred Brand	1	4	000001	1	2	111100000010101000000001	30	60	90							2	30		90							30				34	14		35.00	70.00	105.00																						35.00		70.00																		35.00								35.00				
H4564	005	0	1	18	06	H4564_005_0	6	2	Preferred Brand	1	4	000001	1	2	111100000010101000000001	30	60	90							2	30		90							30				34	14		35.00	70.00	105.00																						35.00		70.00																		35.00								35.00				
H4564	005	0	1	18	06	H4564_005_0	6	3	Non-Preferred Brand	1	4	100000	1	2	111100000010101000000001	30	60	90							2	30		90							30				34	14		65.00	130.00	195.00																						65.00		130.00																		65.00								65.00				
H4564	005	0	1	18	06	H4564_005_0	6	1	Preferred Generic	3	4	001000	1	2	011100000010101000000110	30	60	90							2	30		90							30		34	14				4.00	8.00	12.00																						4.00		8.00																		4.00					4.00					1		
H4564	005	0	1	18	06	H4564_005_0	6	1	Preferred Generic	1	4	001000	1	2	011100000010101000000110	30	60	90							2	30		90							30		34	14				2.00	4.00	6.00																						2.00		4.00																		2.00					2.00							
H4564	005	0	1	18	06	H4564_005_0	6	4	Specialty Tier	1	4	010010	1	1	111100000010101000000111	30	60	90							2	30		90							30		34	14	34	14					354.00	33	33	33																					33		33																	33				33			33			
H4564	006	0	1	18	06	H4564_006_0	6	4	Specialty Tier	1	4	010010	1	1	111100000010101000000111	30	60	90							2	30		90							30		34	14	34	14					354.00	33	33	33																					33		33																	33				33			33			
H4564	006	0	1	18	06	H4564_006_0	6	1	Preferred Generic	3	4	001000	1	2	011100000010101000000110	30	60	90							2	30		90							30		34	14				4.00	8.00	12.00																						4.00		8.00																		4.00					4.00					1		
H4564	006	0	1	18	06	H4564_006_0	6	3	Non-Preferred Brand	1	4	100000	1	2	111100000010101000000001	30	60	90							2	30		90							30				34	14		65.00	130.00	195.00																						65.00		130.00																		65.00								65.00				
H4564	006	0	1	18	06	H4564_006_0	6	2	Preferred Brand	1	4	000001	1	2	111100000010101000000001	30	60	90							2	30		90							30				34	14		35.00	70.00	105.00																						35.00		70.00																		35.00								35.00				
H4564	006	0	1	18	06	H4564_006_0	6	1	Preferred Generic	1	4	001000	1	2	011100000010101000000110	30	60	90							2	30		90							30		34	14				2.00	4.00	6.00																						2.00		4.00																		2.00					2.00							
H4564	017	0	1	18	06	H4564_017_0	6	2	Preferred Brand	1	4	000001	1	2	111100000010101000000001	30	60	90							2	30		90							30				34	14		35.00	70.00	105.00																						35.00		70.00																		35.00								35.00				
H4564	017	0	1	18	06	H4564_017_0	6	1	Preferred Generic	1	4	001000	1	2	011100000010101000000110	30	60	90							2	30		90							30		34	14				7.00	14.00	21.00																						7.00		14.00																		7.00					7.00							
H4564	017	0	1	18	06	H4564_017_0	6	3	Non-Preferred Brand	1	4	100000	1	2	111100000010101000000001	30	60	90							2	30		90							30				34	14		64.00	128.00	192.00																						64.00		128.00																		64.00								64.00				
H4564	017	0	1	18	06	H4564_017_0	6	4	Specialty Tier	1	4	010010	1	1	111100000010101000000111	30	60	90							2	30		90							30		34	14	34	14					354.00	33	33	33																					33		33																	33				33			33			
H4564	018	0	1	18	06	H4564_018_0	6	1	Preferred Generic	1	4	001000	1	2	011100000010101000000110	30	60	90							2	30		90							30		34	14				2.00	4.00	6.00																						2.00		4.00																		2.00					2.00							
H4564	018	0	1	18	06	H4564_018_0	6	2	Preferred Brand	1	4	000001	1	2	111100000010101000000001	30	60	90							2	30		90							30				34	14		35.00	70.00	105.00																						35.00		70.00																		35.00								35.00				
H4564	018	0	1	18	06	H4564_018_0	6	3	Non-Preferred Brand	1	4	100000	1	2	111100000010101000000001	30	60	90							2	30		90							30				34	14		65.00	130.00	195.00																						65.00		130.00																		65.00								65.00				
H4564	018	0	1	18	06	H4564_018_0	6	1	Preferred Generic	3	4	001000	1	2	011100000010101000000110	30	60	90							2	30		90							30		34	14				4.00	8.00	12.00																						4.00		8.00																		4.00					4.00					1		
H4564	018	0	1	18	06	H4564_018_0	6	4	Specialty Tier	1	4	010010	1	1	111100000010101000000111	30	60	90							2	30		90							30		34	14	34	14					354.00	33	33	33																					33		33																	33				33			33			
H4564	021	0	1	18	06	H4564_021_0	6	1	Preferred Generic	1	4	001000	1	2	011100000010101000000110	30	60	90							2	30		90							30		34	14				7.00	14.00	21.00																						7.00		14.00																		7.00					7.00							
H4564	021	0	1	18	06	H4564_021_0	6	3	Non-Preferred Brand	1	4	100000	1	2	111100000010101000000001	30	60	90							2	30		90							30				34	14		64.00	128.00	192.00																						64.00		128.00																		64.00								64.00				
H4564	021	0	1	18	06	H4564_021_0	6	2	Preferred Brand	1	4	000001	1	2	111100000010101000000001	30	60	90							2	30		90							30				34	14		35.00	70.00	105.00																						35.00		70.00																		35.00								35.00				
H4564	021	0	1	18	06	H4564_021_0	6	4	Specialty Tier	1	4	010010	1	1	111100000010101000000111	30	60	90							2	30		90							30		34	14	34	14					354.00	33	33	33																					33		33																	33				33			33			
H4564	022	0	1	18	06	H4564_022_0	6	3	Non-Preferred Brand	1	4	100000	1	2	111100000010101000000001	30	60	90							2	30		90							30				34	14		65.00	130.00	195.00																						65.00		130.00																		65.00								65.00				
H4564	022	0	1	18	06	H4564_022_0	6	1	Preferred Generic	1	4	001000	1	2	011100000010101000000110	30	60	90							2	30		90							30		34	14				2.00	4.00	6.00																						2.00		4.00																		2.00					2.00							
H4564	022	0	1	18	06	H4564_022_0	6	2	Preferred Brand	1	4	000001	1	2	111100000010101000000001	30	60	90							2	30		90							30				34	14		35.00	70.00	105.00																						35.00		70.00																		35.00								35.00				
H4564	022	0	1	18	06	H4564_022_0	6	1	Preferred Generic	3	4	001000	1	2	011100000010101000000110	30	60	90							2	30		90							30		34	14				4.00	8.00	12.00																						4.00		8.00																		4.00					4.00					1		
H4564	022	0	1	18	06	H4564_022_0	6	4	Specialty Tier	1	4	010010	1	1	111100000010101000000111	30	60	90							2	30		90							30		34	14	34	14					354.00	33	33	33																					33		33																	33				33			33			
H4590	010	0	1	01	01	H4590_010_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					5.00		15.00																															2.00							15.00				5.00					5.00							
H4590	010	0	1	01	01	H4590_010_0	7	1	Preferred Generic	3	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					5.00		15.00																															2.00							15.00				5.00					5.00					1		
H4590	010	0	1	01	01	H4590_010_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					187.00	33		33																														33							33			33				33			33			
H4590	010	0	1	01	01	H4590_010_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		92.00		276.00																															266.00							276.00				92.00					92.00			92.00				
H4590	010	0	1	01	01	H4590_010_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H4590	010	0	1	01	01	H4590_010_0	7	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		33.00		99.00																															5.00							99.00				33.00					33.00			33.00				
H4590	012	0	1	01	01	H4590_012_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00							
H4590	012	0	1	01	01	H4590_012_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H4590	012	0	1	01	01	H4590_012_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H4590	012	0	1	01	01	H4590_012_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H4590	012	0	1	01	01	H4590_012_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					602.00	33		33																														33							33			33				33			33			
H4590	012	0	1	01	01	H4590_012_0	7	1	Preferred Generic	3	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00					1		
H4590	012	0	1	01	01	H4590_012_0	7	2	Non-Preferred Generic	3	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00					1		
H4590	025	0	1	01	01	H4590_025_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H4590	025	0	1	01	01	H4590_025_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					465.00	33		33																														33							33			33				33			33			
H4590	025	0	1	01	01	H4590_025_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H4590	025	0	1	01	01	H4590_025_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H4590	025	0	1	01	01	H4590_025_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H4590	037	0	1	01	01	H4590_037_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					5.00		15.00																															2.00							15.00				5.00					5.00							
H4590	037	0	1	01	01	H4590_037_0	7	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		32.00		96.00																															5.00							96.00				32.00					32.00			32.00				
H4590	037	0	1	01	01	H4590_037_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H4590	037	0	1	01	01	H4590_037_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		92.00		276.00																															266.00							276.00				92.00					92.00			92.00				
H4590	037	0	1	01	01	H4590_037_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					475.00	33		33																														33							33			33				33			33			
H4590	037	0	1	01	01	H4590_037_0	7	1	Preferred Generic	3	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					5.00		15.00																															2.00							15.00				5.00					5.00					1		
H4604	003	0	1	01	01	H4604_003_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H4604	003	0	1	01	01	H4604_003_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H4604	003	0	1	01	01	H4604_003_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					423.00	33		33																														33							33			33				33			33			
H4604	003	0	1	01	01	H4604_003_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H4604	003	0	1	01	01	H4604_003_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H4605	002	0	1	04	01	H4605_002_0	9	3	Preferred Brand	1	3	000001		2	110100000010101000000001	30		90							1	30		90							30				31	14	1.50	45.00		135.00																					1.50	45.00		112.50																		45.00							1.45	45.00				
H4605	002	0	1	04	01	H4605_002_0	9	4	Non-Preferred Brand	1	3	100000		2	110100000010101000000001	30		90							1	30		90							30				31	14	3.00	90.00		270.00																					3.00	90.00		225.00																		90.00							2.90	90.00				
H4605	002	0	1	04	01	H4605_002_0	9	5	Specialty Tier	1	3	101101		1	110000000010100000000101	30										30									30		31		31	14					299.00	28																							28																			28				28			28			
H4605	002	0	1	04	01	H4605_002_0	9	6	Injectable Drugs	1	3	101101		1	110000000010100000000101	30										30									30		31		31	14					51.00	28																							28																			28				28			28			
H4605	002	0	1	04	01	H4605_002_0	9	2	Non-Preferred Generic	1	3	000100		2	010100000010101000000100	30		90							1	30		90							30		31				1.10	33.00		99.00																					1.10	33.00		66.00																		33.00				1.06	33.00							
H4605	002	0	1	04	01	H4605_002_0	9	1	Preferred Generic	1	3	001000		2	010100000010101000000100	30		90							1	30		90							30		31				0.25	7.50		22.50																					0.25	7.50		15.00																		7.50				0.24	7.50							
H4605	004	0	1	04	01	H4605_004_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							1	30		90							30		31				0.16	5.00		15.00																					0.16	5.00		10.00																		5.00				0.16	5.00							
H4605	004	0	1	04	01	H4605_004_0	10	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							1	30		90							30				31	14	1.50	45.00		135.00																					1.50	45.00		112.50																		45.00							1.45	45.00				
H4605	004	0	1	04	01	H4605_004_0	10	6	Injectable Drugs	1	4	101101	1	1	110000000010100000000101	30										30									30		31		31	14					60.00	33																							33																			33				33			33			
H4605	004	0	1	04	01	H4605_004_0	10	5	Specialty Tier	1	4	101101	1	1	110000000010100000000101	30										30									30		31		31	14					368.00	33																							33																			33				33			33			
H4605	004	0	1	04	01	H4605_004_0	10	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							1	30		90							30				31	14	3.00	90.00		270.00																					3.00	90.00		225.00																		90.00							2.90	90.00				
H4605	004	0	1	04	01	H4605_004_0	10	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		90							1	30		90							30		31				0.16	5.00		15.00																					0.16	5.00		10.00																		5.00				0.16	5.00					1		
H4605	004	0	1	04	01	H4605_004_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							1	30		90							30		31				1.10	33.00		99.00																					1.10	33.00		66.00																		33.00				1.06	33.00							
H4606	001	0	1	04	01	H4606_001_0	4	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1031.00	33																														33							33					33				33			33	2	3	
H4606	001	0	1	04	01	H4606_001_0	4	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H4606	001	0	1	04	01	H4606_001_0	4	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		42.00		126.00																													42.00		116.00					42.00		126.00				42.00					42.00			42.00		2	2	
H4606	001	0	1	04	01	H4606_001_0	4	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00		2	3	1
H4606	001	0	1	04	01	H4606_001_0	4	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H4606	001	0	1	04	01	H4606_001_0	4	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		42.00		126.00																													42.00		116.00					42.00		126.00				42.00					42.00			42.00				
H4606	001	0	1	04	01	H4606_001_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00				
H4606	001	0	1	04	01	H4606_001_0	4	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					957.00	33																														33							33					33				33			33			
H4606	007	0	1	04	01	H4606_007_0	5	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H4606	007	0	1	04	01	H4606_007_0	5	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H4606	007	0	1	04	01	H4606_007_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00		2	3	1
H4606	007	0	1	04	01	H4606_007_0	5	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					731.00	33																														33							33					33				33			33			
H4606	007	0	1	04	01	H4606_007_0	5	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H4606	007	0	1	04	01	H4606_007_0	5	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H4606	007	0	1	04	01	H4606_007_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H4606	007	0	1	04	01	H4606_007_0	5	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					834.00	33																														33							33					33				33			33	2	3	
H4738	002	0	1	04	01	H4738_002_0	9	3	Non-Preferred Brand	1	4	100100	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		78.00		234.00																						78.00		195.00																		78.00					78.00			78.00				
H4738	002	0	1	04	01	H4738_002_0	9	2	Preferred Brand	1	4	000101	1	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		44.00		132.00																						44.00		110.00																		44.00					44.00			44.00				
H4738	002	0	1	04	01	H4738_002_0	9	1	Preferred Generic	1	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		4.00		12.00																						4.00		10.00																		4.00					4.00			4.00				
H4738	002	0	1	04	01	H4738_002_0	9	4	Specialty Tier	1	4	100100	1	1	110100000010101000000111	30		90							1	30		90							30		31	14	31	14					707.48	33		33																					33		33																	33				33			33			
H4754	001	0	1	04	01	H4754_001_0	12	1	Generic	1	4	010000	1	2	010100000010101000000100	31		93							2	31		93							31		31					5.00		10.00																						5.00		10.00																		5.00					5.00							
H4754	001	0	1	04	01	H4754_001_0	12	4	Specialty Tier	1	4	110001	1	1	110000000010000000000101	31																			31		31		31	14					903.00	33																																										33				33			33			
H4754	001	0	1	04	01	H4754_001_0	12	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		93							2	31		93							31				31	14		80.00		240.00																						80.00		240.00																		80.00								80.00				
H4754	001	0	1	04	01	H4754_001_0	12	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		93							2	31		93							31				31	14		35.00		87.50																						35.00		87.50																		35.00								35.00				
H4754	002	0	1	04	01	H4754_002_0	9	1	Generic	1	4	010000	1	2	010100000010101000000100	31		93							2	31		93							31		31					5.00		10.00																						5.00		10.00																		5.00					5.00							
H4754	002	0	1	04	01	H4754_002_0	9	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		93							2	31		93							31				31	14		40.00		100.00																						40.00		100.00																		40.00								40.00				
H4754	002	0	1	04	01	H4754_002_0	9	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		93							2	31		93							31				31	14		80.00		240.00																						80.00		240.00																		80.00								80.00				
H4754	002	0	1	04	01	H4754_002_0	9	4	Specialty Tier	1	4	110001	1	1	110000000010000000000101	31																			31		31		31	14					903.00	33																																										33				33			33			
H4754	004	0	1	04	01	H4754_004_0	9	1	Generic	1	4	010000	1	2	010100000010101000000100	31		93							2	31		93							31		31					5.00		10.00																						5.00		10.00																		5.00					5.00							
H4754	004	0	1	04	01	H4754_004_0	9	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		93							2	31		93							31				31	14		35.00		87.50																						35.00		87.50																		35.00								35.00				
H4754	004	0	1	04	01	H4754_004_0	9	4	Specialty Tier	1	4	110001	1	1	110000000010000000000101	31																			31		31		31	14					903.00	33																																										33				33			33			
H4754	004	0	1	04	01	H4754_004_0	9	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		93							2	31		93							31				31	14		75.00		225.00																						75.00		225.00																		75.00								75.00				
H4754	007	0	1	04	01	H4754_007_0	8	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		93							2	31		93							31				31	14		88.00		264.00																						88.00		264.00																		88.00								88.00				
H4754	007	0	1	04	01	H4754_007_0	8	1	Generic	1	4	010000	1	2	010100000010101000000100	31		93							2	31		93							31		31					7.00		14.00																						7.00		14.00																		7.00					7.00							
H4754	007	0	1	04	01	H4754_007_0	8	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		93							2	31		93							31				31	14		44.00		110.00																						44.00		110.00																		44.00								44.00				
H4754	007	0	1	04	01	H4754_007_0	8	4	Specialty Tier	1	4	110001	1	1	110000000010000000000101	31																			31		31		31	14					903.00	33																																										33				33			33			
H4754	009	0	1	04	01	H4754_009_0	9	4	Specialty Tier	1	4	110001	1	1	110000000010000000000101	31																			31		31		31	14					903.00	33																																										33				33			33			
H4754	009	0	1	04	01	H4754_009_0	9	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		93							2	31		93							31				31	14		88.00		264.00																						88.00		264.00																		88.00								88.00				
H4754	009	0	1	04	01	H4754_009_0	9	1	Generic	1	4	010000	1	2	010100000010101000000100	31		93							2	31		93							31		31					7.00		14.00																						7.00		14.00																		7.00					7.00							
H4754	009	0	1	04	01	H4754_009_0	9	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		93							2	31		93							31				31	14		44.00		110.00																						44.00		110.00																		44.00								44.00				
H4754	011	0	1	04	01	H4754_011_0	9	1	Generic	1	4	010000	1	2	010100000010101000000100	31		93							2	31		93							31		31					7.00		14.00																						7.00		14.00																		7.00					7.00							
H4754	011	0	1	04	01	H4754_011_0	9	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		93							2	31		93							31				31	14		44.00		110.00																						44.00		110.00																		44.00								44.00				
H4754	011	0	1	04	01	H4754_011_0	9	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		93							2	31		93							31				31	14		88.00		264.00																						88.00		264.00																		88.00								88.00				
H4754	011	0	1	04	01	H4754_011_0	9	4	Specialty Tier	1	4	110001	1	1	110000000010000000000101	31																			31		31		31	14					903.00	33																																										33				33			33			
H4785	001	0	1	09	04	H4785_001_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					774.00	33																														33							33					33				33			33			
H4785	001	0	1	09	04	H4785_001_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00		2	3	1
H4785	001	0	1	09	04	H4785_001_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H4785	001	0	1	09	04	H4785_001_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H4785	001	0	1	09	04	H4785_001_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					892.00	33																														33							33					33				33			33	2	3	
H4785	001	0	1	09	04	H4785_001_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H4785	001	0	1	09	04	H4785_001_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H4785	001	0	1	09	04	H4785_001_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H4785	001	0	1	09	04	H4785_001_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00				
H4785	001	0	1	09	04	H4785_001_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H4866	003	0	1	01	01	H4866_003_0	10	2	Preferred Brand	1	4	000101	1	2	110100000010001000000111	30		90							1			90							30		31	14	31	14		30.00		90.00																								45.00																		30.00					30.00			30.00				
H4866	003	0	1	01	01	H4866_003_0	10	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		70.00		210.00																								105.00																		70.00								70.00				
H4866	003	0	1	01	01	H4866_003_0	10	4	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							2			90							30		31	14	31	14					496.49	30		30																							30																	30				30			30			
H4866	003	0	1	01	01	H4866_003_0	10	1	Generic	1	4	010000	1	2	010100000010001000000110	30		90							1			90							30		31	14			0.00	0.00		0.00																								0.00																		0.00					0.00							
H4871	001	0	1	04	01	H4871_001_0	6	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H4871	001	0	1	04	01	H4871_001_0	6	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H4871	001	0	1	04	01	H4871_001_0	6	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					651.00	33																														33							33					33				33			33	2	3	
H4871	001	0	1	04	01	H4871_001_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		2.00		6.00																													0.00		0.00					2.00		6.00				2.00					2.00			2.00		2	3	1
H4871	001	0	1	04	01	H4871_001_0	6	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					592.00	33																														33							33					33				33			33			
H4871	001	0	1	04	01	H4871_001_0	6	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H4871	001	0	1	04	01	H4871_001_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		2.00		6.00																													0.00		0.00					2.00		6.00				2.00					2.00			2.00				
H4871	001	0	1	04	01	H4871_001_0	6	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H4875	011	0	1	04	01	H4875_011_0	10	4	Specialty Tier	1	4	010010	1	1	110000000010100000000101	31										31									31		31		31	14					405.57	33																							33																			33				33			33			
H4875	011	0	1	04	01	H4875_011_0	10	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		85.00		255.00																						85.00		212.50																		85.00								85.00				
H4875	011	0	1	04	01	H4875_011_0	10	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		40.00		120.00																						40.00		100.00																		40.00								40.00				
H4875	011	0	1	04	01	H4875_011_0	10	1	Generic	1	4	010000	1	2	010100000010101000000100	31		90							1	31		90							31		31					8.00		24.00																						8.00		20.00																		8.00					8.00							
H4875	012	0	1	04	01	H4875_012_0	7	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		85.00		255.00																						85.00		212.50																		85.00								85.00				
H4875	012	0	1	04	01	H4875_012_0	7	4	Specialty Tier	1	4	010010	1	1	110000000010100000000101	31										31									31		31		31	14					405.57	33																							33																			33				33			33			
H4875	012	0	1	04	01	H4875_012_0	7	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		40.00		120.00																						40.00		100.00																		40.00								40.00				
H4875	012	0	1	04	01	H4875_012_0	7	1	Generic	1	4	010000	1	2	010100000010101000000100	31		90							1	31		90							31		31					8.00		24.00																						8.00		20.00																		8.00					8.00							
H4875	013	0	1	04	01	H4875_013_0	8	1	Generic	1	4	010000	1	2	010100000010101000000100	31		90							1	31		90							31		31					8.00		24.00																						8.00		20.00																		8.00					8.00							
H4875	013	0	1	04	01	H4875_013_0	8	4	Specialty Tier	1	4	010010	1	1	110000000010100000000101	31										31									31		31		31	14					405.57	33																							33																			33				33			33			
H4875	013	0	1	04	01	H4875_013_0	8	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		40.00		120.00																						40.00		100.00																		40.00								40.00				
H4875	013	0	1	04	01	H4875_013_0	8	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		85.00		255.00																						85.00		212.50																		85.00								85.00				
H4875	014	0	1	04	01	H4875_014_0	8	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		85.00		255.00																						85.00		212.50																		85.00								85.00				
H4875	014	0	1	04	01	H4875_014_0	8	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		40.00		120.00																						40.00		100.00																		40.00								40.00				
H4875	014	0	1	04	01	H4875_014_0	8	1	Generic	1	4	010000	1	2	010100000010101000000100	31		90							1	31		90							31		31					8.00		24.00																						8.00		20.00																		8.00					8.00							
H4875	014	0	1	04	01	H4875_014_0	8	4	Specialty Tier	1	4	010010	1	1	110000000010100000000101	31										31									31		31		31	14					405.57	33																							33																			33				33			33			
H4875	015	0	1	04	01	H4875_015_0	8	4	Specialty Tier	1	4	010010	1	1	110000000010100000000101	31										31									31		31		31	14					405.57	33																							33																			33				33			33			
H4875	015	0	1	04	01	H4875_015_0	8	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		85.00		255.00																						85.00		212.50																		85.00								85.00				
H4875	015	0	1	04	01	H4875_015_0	8	1	Generic	1	4	010000	1	2	010100000010101000000100	31		90							1	31		90							31		31					8.00		24.00																						8.00		20.00																		8.00					8.00							
H4875	015	0	1	04	01	H4875_015_0	8	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		40.00		120.00																						40.00		100.00																		40.00								40.00				
H4875	016	1	1	04	01	H4875_016_1	9	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		90.00		270.00																						90.00		225.00																		90.00								90.00				
H4875	016	1	1	04	01	H4875_016_1	9	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		45.00		135.00																						45.00		112.50																		45.00								45.00				
H4875	016	1	1	04	01	H4875_016_1	9	1	Generic	1	4	010000	1	2	010100000010101000000100	31		90							1	31		90							31		31					10.00		30.00																						10.00		25.00																		10.00					10.00							
H4875	016	1	1	04	01	H4875_016_1	9	4	Specialty Tier	1	4	010010	1	1	110000000010100000000101	31										31									31		31		31	14					405.57	33																							33																			33				33			33			
H4875	016	2	1	04	01	H4875_016_2	8	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		45.00		135.00																						45.00		112.50																		45.00								45.00				
H4875	016	2	1	04	01	H4875_016_2	8	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		90.00		270.00																						90.00		225.00																		90.00								90.00				
H4875	016	2	1	04	01	H4875_016_2	8	4	Specialty Tier	1	4	010010	1	1	110000000010100000000101	31										31									31		31		31	14					405.57	33																							33																			33				33			33			
H4875	016	2	1	04	01	H4875_016_2	8	1	Generic	1	4	010000	1	2	010100000010101000000100	31		90							1	31		90							31		31					10.00		30.00																						10.00		25.00																		10.00					10.00							
H4875	016	3	1	04	01	H4875_016_3	8	4	Specialty Tier	1	4	010010	1	1	110000000010100000000101	31										31									31		31		31	14					405.57	33																							33																			33				33			33			
H4875	016	3	1	04	01	H4875_016_3	8	1	Generic	1	4	010000	1	2	010100000010101000000100	31		90							1	31		90							31		31					10.00		30.00																						10.00		25.00																		10.00					10.00							
H4875	016	3	1	04	01	H4875_016_3	8	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		45.00		135.00																						45.00		112.50																		45.00								45.00				
H4875	016	3	1	04	01	H4875_016_3	8	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		90.00		270.00																						90.00		225.00																		90.00								90.00				
H4909	009	0	1	04	01	H4909_009_0	13	2	Non-Preferred Generic	1	3	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				8.00	16.00	24.00																						8.00	16.00	12.00																		8.00					8.00							
H4909	009	0	1	04	01	H4909_009_0	13	3	Preferred Brand	1	3	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		41.00	82.00	123.00																						41.00	82.00	102.50																		41.00					41.00			41.00				
H4909	009	0	1	04	01	H4909_009_0	13	4	Non-Preferred Brand	1	3	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		85.00	170.00	255.00																						85.00	170.00	212.50																		85.00					85.00			85.00				
H4909	009	0	1	04	01	H4909_009_0	13	5	Injectable Drugs	1	3	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					77.00	33	33	33																					33	33	33																	33				33			33			
H4909	009	0	1	04	01	H4909_009_0	13	6	Specialty Tier	1	3	010010		1	110000000010100000000111	30										30									30		34	14	34	14					914.00	33																							33																			33				33			33			
H4909	009	0	1	04	01	H4909_009_0	13	1	Preferred Generic	1	3	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				4.00	8.00	12.00																						4.00	8.00	6.00																		4.00					4.00							
H4909	010	0	1	04	01	H4909_010_0	11	5	Injectable Drugs	1	3	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					77.00	33	33	33																					33	33	33																	33				33			33			
H4909	010	0	1	04	01	H4909_010_0	11	4	Non-Preferred Brand	1	3	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		90.00	180.00	270.00																						90.00	180.00	225.00																		90.00					90.00			90.00				
H4909	010	0	1	04	01	H4909_010_0	11	3	Preferred Brand	1	3	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		40.00	80.00	120.00																						40.00	80.00	100.00																		40.00					40.00			40.00				
H4909	010	0	1	04	01	H4909_010_0	11	2	Non-Preferred Generic	1	3	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	14.00	10.50																		7.00					7.00							
H4909	010	0	1	04	01	H4909_010_0	11	1	Preferred Generic	1	3	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				5.00	10.00	15.00																						5.00	10.00	7.50																		5.00					5.00							
H4909	010	0	1	04	01	H4909_010_0	11	6	Specialty Tier	1	3	010010		1	110000000010100000000111	30										30									30		34	14	34	14					914.00	33																							33																			33				33			33			
H4910	005	0	1	01	01	H4910_005_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H4910	005	0	1	01	01	H4910_005_0	6	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					304.86	33	33	33																												33	33	33					33	33	33				33			33			33			
H4910	005	0	1	01	01	H4910_005_0	6	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H4910	005	0	1	01	01	H4910_005_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H4910	005	0	1	01	01	H4910_005_0	6	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					7.00	14.00	21.00																													7.00	14.00	14.00					7.00	14.00	21.00					7.00				7.00							
H4956	001	0	1	04	01	H4956_001_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H4956	001	0	1	04	01	H4956_001_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H4956	001	0	1	04	01	H4956_001_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1146.00	33																														33							33					33				33			33	2	3	
H4956	001	0	1	04	01	H4956_001_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H4956	001	0	1	04	01	H4956_001_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H4956	001	0	1	04	01	H4956_001_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H4956	001	0	1	04	01	H4956_001_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00		2	3	1
H4956	001	0	1	04	01	H4956_001_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					990.00	33																														33							33					33				33			33			
H4956	001	0	1	04	01	H4956_001_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H4956	001	0	1	04	01	H4956_001_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00				
H4956	002	0	1	04	01	H4956_002_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H4956	002	0	1	04	01	H4956_002_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H4956	002	0	1	04	01	H4956_002_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					589.00	33																														33							33					33				33			33			
H4956	002	0	1	04	01	H4956_002_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H4956	002	0	1	04	01	H4956_002_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H4956	002	0	1	04	01	H4956_002_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H4956	002	0	1	04	01	H4956_002_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H4956	002	0	1	04	01	H4956_002_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					712.00	33																														33							33					33				33			33	2	3	
H4956	002	0	1	04	01	H4956_002_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H4956	002	0	1	04	01	H4956_002_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H4956	003	0	1	04	01	H4956_003_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H4956	003	0	1	04	01	H4956_003_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H4956	003	0	1	04	01	H4956_003_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1516.00	33																														33							33					33				33			33	2	3	
H4956	003	0	1	04	01	H4956_003_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00		2	3	1
H4956	003	0	1	04	01	H4956_003_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00				
H4956	003	0	1	04	01	H4956_003_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H4956	003	0	1	04	01	H4956_003_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H4956	003	0	1	04	01	H4956_003_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H4956	003	0	1	04	01	H4956_003_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1306.00	33																														33							33					33				33			33			
H4956	003	0	1	04	01	H4956_003_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H5005	011	0	1	01	01	H5005_011_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H5005	011	0	1	01	01	H5005_011_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H5005	011	0	1	01	01	H5005_011_0	8	2	Non-Preferred Generic	3	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00					1		
H5005	011	0	1	01	01	H5005_011_0	8	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		44.00		132.00																															122.00							132.00				44.00					44.00			44.00				
H5005	011	0	1	01	01	H5005_011_0	8	1	Preferred Generic	3	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00					1		
H5005	011	0	1	01	01	H5005_011_0	8	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					470.00	33		33																														33							33			33				33			33			
H5005	011	0	1	01	01	H5005_011_0	8	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		88.00		264.00																															254.00							264.00				88.00					88.00			88.00				
H5005	019	0	1	01	01	H5005_019_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					4.00		12.00																															8.00							12.00				4.00					4.00							
H5005	019	0	1	01	01	H5005_019_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					7.00		21.00																															14.00							21.00				7.00					7.00							
H5005	019	0	1	01	01	H5005_019_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H5005	019	0	1	01	01	H5005_019_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H5005	019	0	1	01	01	H5005_019_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					508.00	33		33																														33							33			33				33			33			
H5009	002	0	1	04	01	H5009_002_0	9	4	Non-Preferred Brand	1	3	100000		2	110100000010101000000001	30		90							1	30		90							30				31	14	3.00	90.00		270.00																					3.00	90.00		225.00																		90.00							2.90	90.00				
H5009	002	0	1	04	01	H5009_002_0	9	6	Injectable Drugs	1	3	101101		1	110000000010100000000101	30										30									30		31		31	14					50.00	28																							28																			28				28			28			
H5009	002	0	1	04	01	H5009_002_0	9	2	Non-Preferred Generic	1	3	000100		2	010100000010101000000100	30		90							1	30		90							30		31				1.10	33.00		99.00																					1.10	33.00		66.00																		33.00				1.06	33.00							
H5009	002	0	1	04	01	H5009_002_0	9	5	Specialty Tier	1	3	101101		1	110000000010100000000101	30										30									30		31		31	14					399.00	28																							28																			28				28			28			
H5009	002	0	1	04	01	H5009_002_0	9	3	Preferred Brand	1	3	000001		2	110100000010101000000001	30		90							1	30		90							30				31	14	1.50	45.00		135.00																					1.50	45.00		112.50																		45.00							1.45	45.00				
H5009	002	0	1	04	01	H5009_002_0	9	1	Preferred Generic	1	3	001000		2	010100000010101000000100	30		90							1	30		90							30		31				0.25	7.50		22.50																					0.25	7.50		15.00																		7.50				0.24	7.50							
H5009	004	0	1	04	01	H5009_004_0	10	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		90							1	30		90							30		31				0.16	5.00		15.00																					0.16	5.00		10.00																		5.00				0.16	5.00					1		
H5009	004	0	1	04	01	H5009_004_0	10	6	Injectable Drugs	1	4	101101	1	1	110000000010100000000101	30										30									30		31		31	14					62.00	33																							33																			33				33			33			
H5009	004	0	1	04	01	H5009_004_0	10	5	Specialty Tier	1	4	101101	1	1	110000000010100000000101	30										30									30		31		31	14					485.00	33																							33																			33				33			33			
H5009	004	0	1	04	01	H5009_004_0	10	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							1	30		90							30				31	14	3.00	90.00		270.00																					3.00	90.00		225.00																		90.00							2.90	90.00				
H5009	004	0	1	04	01	H5009_004_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							1	30		90							30		31				0.16	5.00		15.00																					0.16	5.00		10.00																		5.00				0.16	5.00							
H5009	004	0	1	04	01	H5009_004_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							1	30		90							30		31				1.10	33.00		99.00																					1.10	33.00		66.00																		33.00				1.06	33.00							
H5009	004	0	1	04	01	H5009_004_0	10	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							1	30		90							30				31	14	1.50	45.00		135.00																					1.50	45.00		112.50																		45.00							1.45	45.00				
H5010	002	0	1	04	01	H5010_002_0	9	5	Specialty Tier	1	3	101101		1	110000000010100000000101	30										30									30		31		31	14					385.00	27																							27																			27				27			27			
H5010	002	0	1	04	01	H5010_002_0	9	4	Non-Preferred Brand	1	3	100000		2	110100000010101000000001	30		90							1	30		90							30				31	14	3.00	90.00		270.00																					3.00	90.00		225.00																		90.00							2.90	90.00				
H5010	002	0	1	04	01	H5010_002_0	9	3	Preferred Brand	1	3	000001		2	110100000010101000000001	30		90							1	30		90							30				31	14	1.50	45.00		135.00																					1.50	45.00		112.50																		45.00							1.45	45.00				
H5010	002	0	1	04	01	H5010_002_0	9	2	Non-Preferred Generic	1	3	000100		2	010100000010101000000100	30		90							1	30		90							30		31				1.10	33.00		99.00																					1.10	33.00		66.00																		33.00				1.06	33.00							
H5010	002	0	1	04	01	H5010_002_0	9	1	Preferred Generic	1	3	001000		2	010100000010101000000100	30		90							1	30		90							30		31				0.25	7.50		22.50																					0.25	7.50		15.00																		7.50				0.24	7.50							
H5010	002	0	1	04	01	H5010_002_0	9	6	Injectable Drugs	1	3	101101		1	110000000010100000000101	30										30									30		31		31	14					52.00	27																							27																			27				27			27			
H5010	004	0	1	04	01	H5010_004_0	10	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		90							1	30		90							30		31				0.16	5.00		15.00																					0.16	5.00		10.00																		5.00				0.16	5.00					1		
H5010	004	0	1	04	01	H5010_004_0	10	6	Injectable Drugs	1	4	101101	1	1	110000000010100000000101	30										30									30		31		31	14					68.00	33																							33																			33				33			33			
H5010	004	0	1	04	01	H5010_004_0	10	5	Specialty Tier	1	4	101101	1	1	110000000010100000000101	30										30									30		31		31	14					447.00	33																							33																			33				33			33			
H5010	004	0	1	04	01	H5010_004_0	10	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							1	30		90							30				31	14	3.00	90.00		270.00																					3.00	90.00		225.00																		90.00							2.90	90.00				
H5010	004	0	1	04	01	H5010_004_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							1	30		90							30		31				1.10	33.00		99.00																					1.10	33.00		66.00																		33.00				1.06	33.00							
H5010	004	0	1	04	01	H5010_004_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							1	30		90							30		31				0.16	5.00		15.00																					0.16	5.00		10.00																		5.00				0.16	5.00							
H5010	004	0	1	04	01	H5010_004_0	10	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							1	30		90							30				31	14	1.50	45.00		135.00																					1.50	45.00		112.50																		45.00							1.45	45.00				
H5016	001	0	1	04	01	H5016_001_0	17	4	Non-Preferred Brand	1	4	100000	1	2	100011111110000111111001				30	60	90	30	60	90	1				30	60	90	30	60	90	30				34	14										70.00	140.00	210.00						70.00	140.00	210.00													70.00	140.00	210.00					70.00	140.00	210.00				70.00								70.00				
H5016	001	0	1	04	01	H5016_001_0	17	3	Preferred Brand	1	4	000001	1	2	100011111110000111111001				30	60	90	30	60	90	1				30	60	90	30	60	90	30				34	14										35.00	70.00	105.00						35.00	70.00	105.00													35.00	70.00	105.00					35.00	70.00	105.00				35.00								35.00				
H5016	001	0	1	04	01	H5016_001_0	17	2	Non-Preferred Generic	1	4	000100	1	2	000011111110000111111110				30	60	90	30	60	90	1				30	60	90	30	60	90	30		34	14												11.00	22.00	33.00						15.00	30.00	45.00													11.00	22.00	33.00					15.00	30.00	45.00				15.00					15.00							
H5016	001	0	1	04	01	H5016_001_0	17	1	Preferred Generic	1	4	001000	1	2	000011111110000111111110				30	60	90	30	60	90	1				30	60	90	30	60	90	30		34	14												6.00	12.00	18.00						9.00	18.00	27.00													6.00	12.00	18.00					9.00	18.00	27.00				9.00					9.00							
H5016	001	0	1	04	01	H5016_001_0	17	6	Specialty Tier	1	4	010010	1	1	100010010010000100100111				30			30							30			30			30		34	14	34	14													150.35	33							150.35	33														33							33					33				33			33			
H5016	001	0	1	04	01	H5016_001_0	17	5	Injectable Drugs	1	4	010010	1	1	100010010010000100100111				30			30							30			30			30		34	14	34	14													48.38	33							48.38	33														33							33					33				33			33			
H5041	001	0	1	04	01	H5041_001_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H5041	001	0	1	04	01	H5041_001_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H5041	001	0	1	04	01	H5041_001_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1138.00	33																														33							33					33				33			33	2	3	
H5041	001	0	1	04	01	H5041_001_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H5041	001	0	1	04	01	H5041_001_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H5041	001	0	1	04	01	H5041_001_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1092.00	33																														33							33					33				33			33			
H5041	001	0	1	04	01	H5041_001_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H5041	001	0	1	04	01	H5041_001_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H5041	001	0	1	04	01	H5041_001_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H5041	001	0	1	04	01	H5041_001_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H5041	002	0	1	04	01	H5041_002_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													6.00		6.00					6.00		18.00				6.00					6.00			6.00				
H5041	002	0	1	04	01	H5041_002_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					792.00	33																														33							33					33				33			33	2	3	
H5041	002	0	1	04	01	H5041_002_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H5041	002	0	1	04	01	H5041_002_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H5041	002	0	1	04	01	H5041_002_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													15.00		15.00					15.00		45.00				15.00					15.00			15.00		2	2	
H5041	002	0	1	04	01	H5041_002_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													6.00		6.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H5041	002	0	1	04	01	H5041_002_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					740.00	33																														33							33					33				33			33			
H5041	002	0	1	04	01	H5041_002_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H5041	002	0	1	04	01	H5041_002_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													15.00		15.00					15.00		45.00				15.00					15.00			15.00				
H5041	002	0	1	04	01	H5041_002_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H5041	003	0	1	04	01	H5041_003_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H5041	003	0	1	04	01	H5041_003_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					912.00	33																														33							33					33				33			33	2	3	
H5041	003	0	1	04	01	H5041_003_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H5041	003	0	1	04	01	H5041_003_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H5041	003	0	1	04	01	H5041_003_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H5041	003	0	1	04	01	H5041_003_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H5041	003	0	1	04	01	H5041_003_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					817.00	33																														33							33					33				33			33			
H5041	003	0	1	04	01	H5041_003_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H5041	003	0	1	04	01	H5041_003_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H5041	003	0	1	04	01	H5041_003_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H5041	006	0	1	04	01	H5041_006_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H5041	006	0	1	04	01	H5041_006_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H5041	006	0	1	04	01	H5041_006_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H5041	006	0	1	04	01	H5041_006_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H5041	006	0	1	04	01	H5041_006_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					944.00	33																														33							33					33				33			33	2	3	
H5041	006	0	1	04	01	H5041_006_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H5041	006	0	1	04	01	H5041_006_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H5041	006	0	1	04	01	H5041_006_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H5041	006	0	1	04	01	H5041_006_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					843.00	33																														33							33					33				33			33			
H5041	006	0	1	04	01	H5041_006_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H5041	007	0	1	04	01	H5041_007_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					921.00	33																														33							33					33				33			33	2	3	
H5041	007	0	1	04	01	H5041_007_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H5041	007	0	1	04	01	H5041_007_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H5041	007	0	1	04	01	H5041_007_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H5041	007	0	1	04	01	H5041_007_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H5041	007	0	1	04	01	H5041_007_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H5041	007	0	1	04	01	H5041_007_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H5041	007	0	1	04	01	H5041_007_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H5041	007	0	1	04	01	H5041_007_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					820.00	33																														33							33					33				33			33			
H5041	007	0	1	04	01	H5041_007_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H5041	008	0	1	04	01	H5041_008_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					894.00	33																														33							33					33				33			33	2	3	
H5041	008	0	1	04	01	H5041_008_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H5041	008	0	1	04	01	H5041_008_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H5041	008	0	1	04	01	H5041_008_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H5041	008	0	1	04	01	H5041_008_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H5041	008	0	1	04	01	H5041_008_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					794.00	33																														33							33					33				33			33			
H5041	008	0	1	04	01	H5041_008_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H5041	008	0	1	04	01	H5041_008_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H5041	008	0	1	04	01	H5041_008_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H5041	008	0	1	04	01	H5041_008_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H5041	009	0	1	04	01	H5041_009_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H5041	009	0	1	04	01	H5041_009_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H5041	009	0	1	04	01	H5041_009_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H5041	009	0	1	04	01	H5041_009_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H5041	009	0	1	04	01	H5041_009_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					927.00	33																														33							33					33				33			33	2	3	
H5041	009	0	1	04	01	H5041_009_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H5041	009	0	1	04	01	H5041_009_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H5041	009	0	1	04	01	H5041_009_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H5041	009	0	1	04	01	H5041_009_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H5041	009	0	1	04	01	H5041_009_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					825.00	33																														33							33					33				33			33			
H5041	011	0	1	04	01	H5041_011_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					820.00	33																														33							33					33				33			33			
H5041	011	0	1	04	01	H5041_011_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H5041	011	0	1	04	01	H5041_011_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H5041	011	0	1	04	01	H5041_011_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H5041	011	0	1	04	01	H5041_011_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H5041	011	0	1	04	01	H5041_011_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					921.00	33																														33							33					33				33			33	2	3	
H5041	011	0	1	04	01	H5041_011_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H5041	011	0	1	04	01	H5041_011_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H5041	011	0	1	04	01	H5041_011_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H5041	011	0	1	04	01	H5041_011_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H5041	012	0	1	04	01	H5041_012_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H5041	012	0	1	04	01	H5041_012_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H5041	012	0	1	04	01	H5041_012_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H5041	012	0	1	04	01	H5041_012_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H5041	012	0	1	04	01	H5041_012_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					921.00	33																														33							33					33				33			33	2	3	
H5041	012	0	1	04	01	H5041_012_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H5041	012	0	1	04	01	H5041_012_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H5041	012	0	1	04	01	H5041_012_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H5041	012	0	1	04	01	H5041_012_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H5041	012	0	1	04	01	H5041_012_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					829.00	33																														33							33					33				33			33			
H5041	013	0	1	04	01	H5041_013_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H5041	013	0	1	04	01	H5041_013_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					894.00	33																														33							33					33				33			33	2	3	
H5041	013	0	1	04	01	H5041_013_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H5041	013	0	1	04	01	H5041_013_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H5041	013	0	1	04	01	H5041_013_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H5041	013	0	1	04	01	H5041_013_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					793.00	33																														33							33					33				33			33			
H5041	013	0	1	04	01	H5041_013_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H5041	013	0	1	04	01	H5041_013_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H5041	013	0	1	04	01	H5041_013_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H5041	013	0	1	04	01	H5041_013_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H5041	014	0	1	04	01	H5041_014_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					921.00	33																														33							33					33				33			33	2	3	
H5041	014	0	1	04	01	H5041_014_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H5041	014	0	1	04	01	H5041_014_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H5041	014	0	1	04	01	H5041_014_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H5041	014	0	1	04	01	H5041_014_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H5041	014	0	1	04	01	H5041_014_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					829.00	33																														33							33					33				33			33			
H5041	014	0	1	04	01	H5041_014_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H5041	014	0	1	04	01	H5041_014_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H5041	014	0	1	04	01	H5041_014_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H5041	014	0	1	04	01	H5041_014_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H5042	001	0	1	04	01	H5042_001_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							1	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00							
H5042	001	0	1	04	01	H5042_001_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							1	30		90							30		31					8.00		24.00																						8.00		16.00																		8.00					8.00							
H5042	001	0	1	04	01	H5042_001_0	10	3	Preferred Brand	1	4	010001	1	2	110100000010101000000101	30		90							1	30		90							30		31		31	14		40.00		120.00																						40.00		80.00																		40.00					40.00			40.00				
H5042	001	0	1	04	01	H5042_001_0	10	4	Non-Preferred Brand	1	4	110000	1	2	110100000010101000000101	30		90							1	30		90							30		31		31	14		90.00		270.00																						90.00		225.00																		90.00					90.00			90.00				
H5042	001	0	1	04	01	H5042_001_0	10	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					736.04	30																							30																			30				30			30			
H5042	001	0	1	04	01	H5042_001_0	10	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		90							1	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00					1		
H5042	001	0	1	04	01	H5042_001_0	10	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000100	30		90							1	30		90							30		31					8.00		24.00																						8.00		16.00																		8.00					8.00					1		
H5042	005	0	1	04	01	H5042_005_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							1	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00							
H5042	005	0	1	04	01	H5042_005_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							1	30		90							30		31					9.00		27.00																						9.00		18.00																		9.00					9.00							
H5042	005	0	1	04	01	H5042_005_0	10	3	Preferred Brand	1	4	010001	1	2	110100000010101000000101	30		90							1	30		90							30		31		31	14		45.00		135.00																						45.00		90.00																		45.00					45.00			45.00				
H5042	005	0	1	04	01	H5042_005_0	10	4	Non-Preferred Brand	1	4	110000	1	2	110100000010101000000101	30		90							1	30		90							30		31		31	14		95.00		285.00																						95.00		237.50																		95.00					95.00			95.00				
H5042	005	0	1	04	01	H5042_005_0	10	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					824.71	33																							33																			33				33			33			
H5042	007	0	1	04	01	H5042_007_0	10	3	Preferred Brand	1	4	010001	1	2	110100000010101000000101	30		90							1	30		90							30		31		31	14		40.00		120.00																						40.00		80.00																		40.00					40.00			40.00				
H5042	007	0	1	04	01	H5042_007_0	10	4	Non-Preferred Brand	1	4	110000	1	2	110100000010101000000101	30		90							1	30		90							30		31		31	14		75.00		225.00																						75.00		187.50																		75.00					75.00			75.00				
H5042	007	0	1	04	01	H5042_007_0	10	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					645.93	30																							30																			30				30			30			
H5042	007	0	1	04	01	H5042_007_0	10	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		90							1	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00					1		
H5042	007	0	1	04	01	H5042_007_0	10	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000100	30		90							1	30		90							30		31					5.00		15.00																						5.00		10.00																		5.00					5.00					1		
H5042	007	0	1	04	01	H5042_007_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							1	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00							
H5042	007	0	1	04	01	H5042_007_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							1	30		90							30		31					5.00		15.00																						5.00		10.00																		5.00					5.00							
H5050	004	0	1	01	01	H5050_004_0	6	4	Non-Preferred Brand	1	4	100000	1	1	110100000010101000000001	30		90							1	30		90							30				31	14					90.61	50		50																					50		50																	50							50			
H5050	004	0	1	01	01	H5050_004_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							1	30		90							30		31					4.00		12.00																						4.00		12.00																		4.00					4.00							
H5050	004	0	1	01	01	H5050_004_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							1	30		90							30				31	14		25.00		75.00																						25.00		75.00																		25.00								25.00				
H5050	004	0	1	01	01	H5050_004_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							1	30		90							30		31					20.00		60.00																						20.00		60.00																		20.00					20.00							
H5050	009	0	1	01	01	H5050_009_0	7	4	Non-Preferred Brand	1	3	100000		1	110100000010101000000001	30		90							1	30		90							30				31	14					93.46	50		50																					50		50																	50							50			
H5050	009	0	1	01	01	H5050_009_0	7	3	Preferred Brand	1	3	000001		2	110100000010101000000001	30		90							1	30		90							30				31	14		20.00		60.00																						20.00		60.00																		20.00								20.00				
H5050	009	0	1	01	01	H5050_009_0	7	2	Non-Preferred Generic	1	3	000100		2	010100000010101000000100	30		90							1	30		90							30		31					18.00		54.00																						18.00		54.00																		18.00					18.00							
H5050	009	0	1	01	01	H5050_009_0	7	1	Preferred Generic	1	3	001000		2	010100000010101000000100	30		90							1	30		90							30		31					4.00		12.00																						4.00		12.00																		4.00					4.00							
H5050	013	0	1	01	01	H5050_013_0	6	4	Non-Preferred Brand	1	3	100000		1	110100000010101000000001	30		90							1	30		90							30				31	14					87.41	50		50																					50		50																	50							50			
H5050	013	0	1	01	01	H5050_013_0	6	2	Non-Preferred Generic	1	3	000100		2	010100000010101000000100	30		90							1	30		90							30		31					9.00		27.00																						9.00		27.00																		9.00					9.00							
H5050	013	0	1	01	01	H5050_013_0	6	3	Preferred Brand	1	3	000001		2	110100000010101000000001	30		90							1	30		90							30				31	14		13.00		39.00																						13.00		39.00																		13.00								13.00				
H5050	013	0	1	01	01	H5050_013_0	6	1	Preferred Generic	1	3	001000		2	010100000010101000000100	30		90							1	30		90							30		31					3.00		9.00																						3.00		9.00																		3.00					3.00							
H5087	001	0	1	01	01	H5087_001_0	14	5	Specialty Tier	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		31	3	31	14					100.00	25	25	25																					25	25	25																	25				25			25			
H5087	001	0	1	01	01	H5087_001_0	14	2	Non-Preferred Generic	1	4	000100	1	1	011100000010111000000110	30	60	90							1	30	60	90							30		31	3							100.00	25	25	25																					25	25	25																	25				25						
H5087	001	0	1	01	01	H5087_001_0	14	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		31	3				0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00							
H5087	001	0	1	01	01	H5087_001_0	14	4	Non-Preferred Brand	1	4	100000	1	1	111100000010111000000001	30	60	90							1	30	60	90							30				31	14					100.00	25	25	25																					25	25	25																	25							25			
H5087	001	0	1	01	01	H5087_001_0	14	3	Preferred Brand	1	4	000001	3	1	111100000010111000000001	30	60	90							1	30	60	90							30				31	14					100.00	25	25	25																					25	25	25																	25							25			
H5087	002	0	1	01	01	H5087_002_0	15	5	Specialty Tier	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		31	3	31	14					100.00	25	25	25																					25	25	25																	25				25			25			
H5087	002	0	1	01	01	H5087_002_0	15	4	Non-Preferred Brand	1	4	100000	1	1	111100000010111000000001	30	60	90							1	30	60	90							30				31	14					100.00	25	25	25																					25	25	25																	25							25			
H5087	002	0	1	01	01	H5087_002_0	15	3	Preferred Brand	1	4	000001	3	1	111100000010111000000001	30	60	90							1	30	60	90							30				31	14					100.00	25	25	25																					25	25	25																	25							25			
H5087	002	0	1	01	01	H5087_002_0	15	2	Non-Preferred Generic	1	4	000100	1	1	011100000010111000000110	30	60	90							1	30	60	90							30		31	3							100.00	25	25	25																					25	25	25																	25				25						
H5087	002	0	1	01	01	H5087_002_0	15	1	Preferred Generic	1	4	001000	1	1	011100000010111000000110	30	60	90							1	30	60	90							30		31	3							50.00	25	25	25																					25	25	25																	25				25						
H5087	005	0	1	01	01	H5087_005_0	11	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		31	3				0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00							
H5087	005	0	1	01	01	H5087_005_0	11	2	Non-Preferred Generic	3	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		31	3				10.00	20.00	20.00																						10.00	20.00	20.00																		10.00					10.00					1		
H5087	005	0	1	01	01	H5087_005_0	11	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		31	3				0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00					1		
H5087	005	0	1	01	01	H5087_005_0	11	5	Specialty Tier	1	4	100100	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		31	3	31	14					100.00	25	25	25																					25	25	25																	25				25			25			
H5087	005	0	1	01	01	H5087_005_0	11	4	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	3		90.00	180.00	180.00																						90.00	180.00	180.00																		90.00								90.00				
H5087	005	0	1	01	01	H5087_005_0	11	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		31	3				10.00	20.00	20.00																						10.00	20.00	20.00																		10.00					10.00							
H5087	005	0	1	01	01	H5087_005_0	11	3	Preferred Brand	1	4	000001	3	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	3		40.00	80.00	80.00																						40.00	80.00	80.00																		40.00								40.00				
H5087	007	0	1	01	01	H5087_007_0	13	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		31	3				0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00							
H5087	007	0	1	01	01	H5087_007_0	13	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		31	3				10.00	20.00	20.00																						10.00	20.00	30.00																		10.00					10.00							
H5087	007	0	1	01	01	H5087_007_0	13	3	Preferred Brand	1	4	000001	3	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	3		40.00	80.00	80.00																						40.00	80.00	80.00																		40.00								40.00				
H5087	007	0	1	01	01	H5087_007_0	13	4	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	3		90.00	180.00	180.00																						90.00	180.00	180.00																		90.00								90.00				
H5087	007	0	1	01	01	H5087_007_0	13	5	Specialty Tier	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		31	3	31	14					100.00	25	25	25																					25	25	25																	25				25			25			
H5087	007	0	1	01	01	H5087_007_0	13	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		31	3				0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00					1		
H5087	007	0	1	01	01	H5087_007_0	13	2	Non-Preferred Generic	3	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		31	3				10.00	20.00	20.00																						10.00	20.00	20.00																		10.00					10.00					1		
H5087	008	0	1	01	01	H5087_008_0	15	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		31	3				0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00							
H5087	008	0	1	01	01	H5087_008_0	15	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		31	3				10.00	20.00	20.00																						10.00	20.00	30.00																		10.00					10.00							
H5087	008	0	1	01	01	H5087_008_0	15	3	Preferred Brand	1	4	000001	3	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	3		40.00	80.00	80.00																						40.00	80.00	80.00																		40.00								40.00				
H5087	008	0	1	01	01	H5087_008_0	15	4	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	3		90.00	180.00	180.00																						90.00	180.00	180.00																		90.00								90.00				
H5087	008	0	1	01	01	H5087_008_0	15	5	Specialty Tier	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		31	3	31	14					100.00	25	25	25																					25	25	25																	25				25			25			
H5087	008	0	1	01	01	H5087_008_0	15	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		31	3				0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00					1		
H5087	008	0	1	01	01	H5087_008_0	15	2	Non-Preferred Generic	3	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		31	3				10.00	20.00	20.00																						10.00	20.00	20.00																		10.00					10.00					1		
H5087	009	0	1	01	01	H5087_009_0	14	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		31	3				0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00					1		
H5087	009	0	1	01	01	H5087_009_0	14	5	Specialty Tier	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		31	3	31	14					100.00	25	25	25																					25	25	25																	25				25			25			
H5087	009	0	1	01	01	H5087_009_0	14	4	Non-Preferred Brand	1	4	100000	1	1	111100000010111000000001	30	60	90							1	30	60	90							30				31	14					100.00	25	25	25																					25	25	25																	25							25			
H5087	009	0	1	01	01	H5087_009_0	14	3	Preferred Brand	1	4	000001	3	1	111100000010111000000001	30	60	90							1	30	60	90							30				31	14					100.00	25	25	25																					25	25	25																	25							25			
H5087	009	0	1	01	01	H5087_009_0	14	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		31	3				20.00	40.00	40.00																						20.00	40.00	40.00																		20.00					20.00							
H5087	009	0	1	01	01	H5087_009_0	14	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		31	3				0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00							
H5087	009	0	1	01	01	H5087_009_0	14	2	Non-Preferred Generic	3	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		31	3				20.00	40.00	40.00																						20.00	40.00	40.00																		20.00					20.00					1		
H5087	010	0	1	01	01	H5087_010_0	13	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		31	3				0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00							
H5087	010	0	1	01	01	H5087_010_0	13	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		31	3				10.00	20.00	20.00																						10.00	20.00	20.00																		10.00					10.00							
H5087	010	0	1	01	01	H5087_010_0	13	3	Preferred Brand	1	4	000001	3	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	3		40.00	80.00	80.00																						40.00	80.00	80.00																		40.00								40.00				
H5087	010	0	1	01	01	H5087_010_0	13	4	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	3		90.00	180.00	180.00																						90.00	180.00	180.00																		90.00								90.00				
H5087	010	0	1	01	01	H5087_010_0	13	2	Non-Preferred Generic	3	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		31	3				10.00	20.00	20.00																						10.00	20.00	20.00																		10.00					10.00					1		
H5087	010	0	1	01	01	H5087_010_0	13	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		31	3				0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00					1		
H5087	010	0	1	01	01	H5087_010_0	13	5	Specialty Tier	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		31	3	31	14					100.00	25	25	25																					25	25	25																	25				25			25			
H5096	001	0	1	04	01	H5096_001_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14				3.00		9.00																						3.00	6.00	6.00																		3.00					3.00							
H5096	001	0	1	04	01	H5096_001_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14				10.00		30.00																						10.00	20.00	20.00																		10.00					10.00							
H5096	001	0	1	04	01	H5096_001_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010111000000111	31		90							1	31	60	90							31		34	14	34	14		45.00		135.00																						45.00	90.00	135.00																		45.00					45.00			45.00				
H5096	001	0	1	04	01	H5096_001_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110100000010111000000001	31		90							1	31	60	90							31				34	14		95.00		285.00																						95.00	190.00	285.00																		95.00								95.00				
H5096	001	0	1	04	01	H5096_001_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010111000000111	31		90							1	31	60	90							31		34	14	34	14					100.00	33		33																					33	33	33																	33				33			33			
H5096	003	0	1	04	01	H5096_003_0	5	1	Preferred Generic	1	4	001000	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14				0.00		0.00																						0.00	0.00	0.00																		0.00					0.00							
H5096	003	0	1	04	01	H5096_003_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14				6.00		18.00																						6.00	12.00	12.00																		6.00					6.00							
H5096	003	0	1	04	01	H5096_003_0	5	3	Preferred Brand	1	4	010001	1	2	110100000010111000000111	31		90							1	31	60	90							31		34	14	34	14		45.00		135.00																						45.00	90.00	135.00																		45.00					45.00			45.00				
H5096	003	0	1	04	01	H5096_003_0	5	4	Non-Preferred Brand	1	4	100000	1	2	110100000010111000000001	31		90							1	31	60	90							31				34	14		95.00		285.00																						95.00	190.00	285.00																		95.00								95.00				
H5096	003	0	1	04	01	H5096_003_0	5	5	Specialty Tier	1	4	010010	1	1	110100000010111000000111	31		90							1	31	60	90							31		34	14	34	14					100.00	33		33																					33	33	33																	33				33			33			
H5106	013	0	1	04	01	H5106_013_0	7	4	Specialty Tier	1	4	010010	1	1	110100000010001000000101	34		90							1			90							34		34		34	14					709.72	33		33																							33																	33				33			33			
H5106	013	0	1	04	01	H5106_013_0	7	1	Generic	1	4	010000	1	2	010100000010001000000100	34		90							1			90							34		34					10.00		30.00																								25.00																		10.00					10.00							
H5106	013	0	1	04	01	H5106_013_0	7	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	34		90							1			90							34				34	14		45.00		135.00																								112.50																		45.00								45.00				
H5106	013	0	1	04	01	H5106_013_0	7	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	34		90							1			90							34				34	14		90.00		270.00																								225.00																		90.00								90.00				
H5106	014	0	1	04	01	H5106_014_0	8	1	Generic	1	4	010000	1	2	010100000010001000000100	34		90							1			90							34		34					10.00		30.00																								25.00																		10.00					10.00							
H5106	014	0	1	04	01	H5106_014_0	8	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	34		90							1			90							34				34	14		45.00		135.00																								112.50																		45.00								45.00				
H5106	014	0	1	04	01	H5106_014_0	8	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	34		90							1			90							34				34	14		90.00		270.00																								225.00																		90.00								90.00				
H5106	014	0	1	04	01	H5106_014_0	8	4	Specialty Tier	1	4	010010	1	1	110100000010001000000101	34		90							1			90							34		34		34	14					650.70	33		33																							33																	33				33			33			
H5106	014	0	1	04	01	H5106_014_0	8	1	Generic	3	4	010000	1	1	010100000010001000000100	34		90							1			90							34		34								19.70	50		50																							50																	50				50				1		
H5106	015	0	1	04	01	H5106_015_0	7	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	34		90							1			90							34				34	14		45.00		135.00																								112.50																		45.00								45.00				
H5106	015	0	1	04	01	H5106_015_0	7	1	Generic	1	4	010000	1	2	010100000010001000000100	34		90							1			90							34		34					10.00		30.00																								25.00																		10.00					10.00							
H5106	015	0	1	04	01	H5106_015_0	7	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	34		90							1			90							34				34	14		90.00		270.00																								225.00																		90.00								90.00				
H5106	015	0	1	04	01	H5106_015_0	7	4	Specialty Tier	1	4	010010	1	1	110100000010001000000101	34		90							1			90							34		34		34	14					709.72	33		33																							33																	33				33			33			
H5106	016	0	1	04	01	H5106_016_0	8	4	Specialty Tier	1	4	010010	1	1	110100000010001000000101	34		90							1			90							34		34		34	14					650.70	33		33																							33																	33				33			33			
H5106	016	0	1	04	01	H5106_016_0	8	1	Generic	1	4	010000	1	2	010100000010001000000100	34		90							1			90							34		34					10.00		30.00																								25.00																		10.00					10.00							
H5106	016	0	1	04	01	H5106_016_0	8	1	Generic	3	4	010000	1	1	010100000010001000000100	34		90							1			90							34		34								19.70	50		50																							50																	50				50				1		
H5106	016	0	1	04	01	H5106_016_0	8	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	34		90							1			90							34				34	14		45.00		135.00																								112.50																		45.00								45.00				
H5106	016	0	1	04	01	H5106_016_0	8	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	34		90							1			90							34				34	14		90.00		270.00																								225.00																		90.00								90.00				
H5106	025	0	1	04	01	H5106_025_0	10	1	Generic	1	4	010000	1	2	010100000010001000000100	34		90							1			90							34		34					9.00		27.00																								22.50																		9.00					9.00							
H5106	025	0	1	04	01	H5106_025_0	10	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	34		90							1			90							34				34	14		45.00		135.00																								112.50																		45.00								45.00				
H5106	025	0	1	04	01	H5106_025_0	10	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	34		90							1			90							34				34	14		90.00		270.00																								225.00																		90.00								90.00				
H5106	025	0	1	04	01	H5106_025_0	10	4	Specialty Tier	1	4	010010	1	1	110100000010001000000101	34		90							1			90							34		34		34	14					619.15	29		29																							29																	29				29			29			
H5106	026	0	1	04	01	H5106_026_0	12	1	Generic	1	4	010000	1	2	010100000010001000000100	34		90							1			90							34		34					9.00		27.00																								22.50																		9.00					9.00							
H5106	026	0	1	04	01	H5106_026_0	12	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	34		90							1			90							34				34	14		45.00		135.00																								112.50																		45.00								45.00				
H5106	026	0	1	04	01	H5106_026_0	12	4	Specialty Tier	1	4	010010	1	1	110100000010001000000101	34		90							1			90							34		34		34	14					619.15	29		29																							29																	29				29			29			
H5106	026	0	1	04	01	H5106_026_0	12	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	34		90							1			90							34				34	14		90.00		270.00																								225.00																		90.00								90.00				
H5141	001	0	1	04	01	H5141_001_0	14	5	Specialty Tier	1	2	000010		1	111100000010001000000001	30	60	90							1			90							30				31	1					25.00	25	25	25																							25																	25							25			
H5141	001	0	1	04	01	H5141_001_0	14	4	Non-Preferred Brand	1	2	100000		2	111100000010001000000001	30	60	90							1			90							30				31	1		75.00	150.00	225.00																								150.00																		75.00								75.00				
H5141	001	0	1	04	01	H5141_001_0	14	3	Preferred Brand	1	2	000001		2	111100000010001000000001	30	60	90							1			90							30				31	1		40.00	80.00	120.00																								80.00																		40.00								40.00				
H5141	001	0	1	04	01	H5141_001_0	14	1	Preferred Generic	1	2	001000		2	011100000010001000000110	30	60	90							1			90							30		31	1				0.00	0.00	0.00																								0.00																		0.00					0.00							
H5141	001	0	1	04	01	H5141_001_0	14	2	Non-Preferred Generic	1	2	000100		2	011100000010001000000110	30	60	90							1			90							30		31	1				14.00	28.00	42.00																								28.00																		14.00					14.00							
H5151	002	0	1	01	01	H5151_002_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				8.00		24.00																								16.00																		8.00					8.00							
H5151	002	0	1	01	01	H5151_002_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				15.00		45.00																								30.00																		15.00					15.00							
H5151	002	0	1	01	01	H5151_002_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		40.00		120.00																								80.00																		40.00								40.00				
H5151	002	0	1	01	01	H5151_002_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							2			90							30				31	14		95.00		285.00																								190.00																		95.00								95.00				
H5151	002	0	1	01	01	H5151_002_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		31	14	31	14					1000.16	33																							33																			33				33			33			
H5151	002	0	1	01	01	H5151_002_0	9	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				8.00		24.00																								16.00																		8.00					8.00					1		
H5151	002	0	1	01	01	H5151_002_0	9	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				15.00		45.00																								30.00																		15.00					15.00					1		
H5151	006	0	1	01	01	H5151_006_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				3.00		9.00																								6.00																		3.00					3.00							
H5151	006	0	1	01	01	H5151_006_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				10.00		30.00																								20.00																		10.00					10.00							
H5151	006	0	1	01	01	H5151_006_0	10	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		35.00		105.00																								70.00																		35.00								35.00				
H5151	006	0	1	01	01	H5151_006_0	10	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							2			90							30				31	14		95.00		285.00																								190.00																		95.00								95.00				
H5151	006	0	1	01	01	H5151_006_0	10	5	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		31	14	31	14					1023.52	33																							33																			33				33			33			
H5151	006	0	1	01	01	H5151_006_0	10	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				3.00		9.00																								6.00																		3.00					3.00					1		
H5151	006	0	1	01	01	H5151_006_0	10	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				10.00		30.00																								20.00																		10.00					10.00					1		
H5190	001	0	1	01	01	H5190_001_0	11	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							2			90							30				31	7		95.00		95.00																								95.00																		95.00								95.00				
H5190	001	0	1	01	01	H5190_001_0	11	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	7		45.00		45.00																								45.00																		45.00								45.00				
H5190	001	0	1	01	01	H5190_001_0	11	1	Generic	1	4	010000	1	2	010100000010001000000100	30		90							2			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H5190	001	0	1	01	01	H5190_001_0	11	4	Injectable Drugs	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	7		95.00		95.00																								95.00																		95.00								95.00				
H5211	002	0	1	02	01	H5211_002_0	6	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				34	14		45.00	90.00	135.00																						45.00	90.00	135.00																		45.00								45.00				
H5211	002	0	1	02	01	H5211_002_0	6	1	Generic	1	4	010010	1	2	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14		6.00	12.00	18.00																						6.00	12.00	18.00																		6.00					6.00			6.00				
H5211	002	0	1	02	01	H5211_002_0	6	1	Generic	3	4	010010	1	2	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14		6.00	12.00	18.00																						6.00	12.00	18.00																		6.00					6.00			6.00		2	3	
H5211	002	0	1	02	01	H5211_002_0	6	4	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		34		34	14					816.00	33																							33																			33				33			33			
H5211	002	0	1	02	01	H5211_002_0	6	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				34	14		90.00	180.00	270.00																						90.00	180.00	270.00																		90.00								90.00				
H5211	004	0	1	02	01	H5211_004_0	6	1	Generic	1	4	010010	1	2	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14		6.00	12.00	18.00																						6.00	12.00	18.00																		6.00					6.00			6.00				
H5211	004	0	1	02	01	H5211_004_0	6	1	Generic	3	4	010010	1	2	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14		6.00	12.00	18.00																						6.00	12.00	18.00																		6.00					6.00			6.00		2	3	
H5211	004	0	1	02	01	H5211_004_0	6	4	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		34		34	14					782.00	33																							33																			33				33			33			
H5211	004	0	1	02	01	H5211_004_0	6	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				34	14		90.00	180.00	270.00																						90.00	180.00	270.00																		90.00								90.00				
H5211	004	0	1	02	01	H5211_004_0	6	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				34	14		45.00	90.00	135.00																						45.00	90.00	135.00																		45.00								45.00				
H5211	005	0	1	02	01	H5211_005_0	8	4	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		34		34	14					713.00	33																							33																			33				33			33			
H5211	005	0	1	02	01	H5211_005_0	8	1	Generic	3	4	010010	1	2	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14		6.00	12.00	18.00																						6.00	12.00	18.00																		6.00					6.00			6.00		2	3	
H5211	005	0	1	02	01	H5211_005_0	8	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				34	14		90.00	180.00	270.00																						90.00	180.00	270.00																		90.00								90.00				
H5211	005	0	1	02	01	H5211_005_0	8	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				34	14		45.00	90.00	135.00																						45.00	90.00	135.00																		45.00								45.00				
H5211	005	0	1	02	01	H5211_005_0	8	1	Generic	1	4	010010	1	2	111100000010111000000101	30	60	90							1	30	60	90							30		34		34	14		6.00	12.00	18.00																						6.00	12.00	18.00																		6.00					6.00			6.00				
H5214	003	0	1	04	01	H5214_003_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H5214	003	0	1	04	01	H5214_003_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					866.00	33																														33							33					33				33			33			
H5214	003	0	1	04	01	H5214_003_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H5214	003	0	1	04	01	H5214_003_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H5214	003	0	1	04	01	H5214_003_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H5214	003	0	1	04	01	H5214_003_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H5214	003	0	1	04	01	H5214_003_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					908.00	33																														33							33					33				33			33	2	3	
H5214	003	0	1	04	01	H5214_003_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H5214	003	0	1	04	01	H5214_003_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H5214	003	0	1	04	01	H5214_003_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H5214	004	0	1	04	01	H5214_004_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H5214	004	0	1	04	01	H5214_004_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					737.00	33																														33							33					33				33			33			
H5214	004	0	1	04	01	H5214_004_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H5214	004	0	1	04	01	H5214_004_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H5214	004	0	1	04	01	H5214_004_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H5214	004	0	1	04	01	H5214_004_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H5214	004	0	1	04	01	H5214_004_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					798.00	33																														33							33					33				33			33	2	3	
H5214	004	0	1	04	01	H5214_004_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H5214	004	0	1	04	01	H5214_004_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H5214	004	0	1	04	01	H5214_004_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H5214	008	0	1	04	01	H5214_008_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00				
H5214	008	0	1	04	01	H5214_008_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H5214	008	0	1	04	01	H5214_008_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H5214	008	0	1	04	01	H5214_008_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H5214	008	0	1	04	01	H5214_008_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1054.00	33																														33							33					33				33			33			
H5214	008	0	1	04	01	H5214_008_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00		2	3	1
H5214	008	0	1	04	01	H5214_008_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H5214	008	0	1	04	01	H5214_008_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H5214	008	0	1	04	01	H5214_008_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H5214	008	0	1	04	01	H5214_008_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1155.00	33																														33							33					33				33			33	2	3	
H5214	009	0	1	04	01	H5214_009_0	4	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H5214	009	0	1	04	01	H5214_009_0	4	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H5214	009	0	1	04	01	H5214_009_0	4	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H5214	009	0	1	04	01	H5214_009_0	4	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00		2	3	1
H5214	009	0	1	04	01	H5214_009_0	4	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					708.00	33																														33							33					33				33			33	2	3	
H5214	009	0	1	04	01	H5214_009_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H5214	009	0	1	04	01	H5214_009_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H5214	009	0	1	04	01	H5214_009_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H5214	009	0	1	04	01	H5214_009_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00				
H5214	009	0	1	04	01	H5214_009_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					637.00	33																														33							33					33				33			33			
H5214	011	0	1	04	01	H5214_011_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H5214	011	0	1	04	01	H5214_011_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					916.00	33																														33							33					33				33			33	2	3	
H5214	011	0	1	04	01	H5214_011_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H5214	011	0	1	04	01	H5214_011_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H5214	011	0	1	04	01	H5214_011_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H5214	011	0	1	04	01	H5214_011_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00		2	3	1
H5214	011	0	1	04	01	H5214_011_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					810.00	33																														33							33					33				33			33			
H5214	011	0	1	04	01	H5214_011_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H5214	011	0	1	04	01	H5214_011_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H5214	011	0	1	04	01	H5214_011_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00				
H5214	012	0	1	04	01	H5214_012_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H5214	012	0	1	04	01	H5214_012_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H5214	012	0	1	04	01	H5214_012_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H5214	012	0	1	04	01	H5214_012_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00				
H5214	012	0	1	04	01	H5214_012_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H5214	012	0	1	04	01	H5214_012_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H5214	012	0	1	04	01	H5214_012_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00		2	3	1
H5214	012	0	1	04	01	H5214_012_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					683.00	33																														33							33					33				33			33			
H5214	012	0	1	04	01	H5214_012_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					769.00	33																														33							33					33				33			33	2	3	
H5214	012	0	1	04	01	H5214_012_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H5214	014	0	1	04	01	H5214_014_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					920.00	33																														33							33					33				33			33	2	3	
H5214	014	0	1	04	01	H5214_014_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H5214	014	0	1	04	01	H5214_014_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H5214	014	0	1	04	01	H5214_014_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H5214	014	0	1	04	01	H5214_014_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00		2	3	1
H5214	014	0	1	04	01	H5214_014_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					816.00	33																														33							33					33				33			33			
H5214	014	0	1	04	01	H5214_014_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H5214	014	0	1	04	01	H5214_014_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H5214	014	0	1	04	01	H5214_014_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00				
H5214	014	0	1	04	01	H5214_014_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H5215	002	0	1	04	01	H5215_002_0	9	4	Non-Preferred Brand	1	4	100000	1	2	100010110110101000000001				31		90	31		90	1	31		90							31				31	14										70.00		189.00						75.00		203.00						70.00		189.00																		70.00								70.00				
H5215	002	0	1	04	01	H5215_002_0	9	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				31			31				31									31		31		31	14													607.00	33							607.00	33							33																			33				33			33			
H5215	002	0	1	04	01	H5215_002_0	9	1	Preferred Generic	3	4	001000	1	2	000010110110101000000100				31		90	31		90	1	31		90							31		31													1.00		2.00						3.00		8.00						1.00		2.00																		1.00					1.00					1		
H5215	002	0	1	04	01	H5215_002_0	9	2	Non-Preferred Generic	3	4	001100	1	2	000010110110101000000100				31		90	31		90	1	31		90							31		31													9.00		21.00						14.00		34.00						9.00		21.00																		9.00					9.00					1		
H5215	002	0	1	04	01	H5215_002_0	9	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				31		90	31		90	1	31		90							31		31													1.00		2.00						3.00		8.00						1.00		2.00																		1.00					1.00							
H5215	002	0	1	04	01	H5215_002_0	9	2	Non-Preferred Generic	1	4	001100	1	2	000010110110101000000100				31		90	31		90	1	31		90							31		31													8.00		20.00						13.00		33.00						8.00		20.00																		8.00					8.00							
H5215	002	0	1	04	01	H5215_002_0	9	3	Preferred Brand	1	4	000101	1	2	100010110110101000000101				31		90	31		90	1	31		90							31		31		31	14										40.00		97.00						45.00		109.00						40.00		97.00																		40.00					40.00			40.00				
H5215	005	0	1	04	01	H5215_005_0	8	2	Non-Preferred Generic	1	4	001100	1	2	000010110110101000000100				31		90	31		90	1	31		90							31		31													8.00		20.00						13.00		33.00						8.00		20.00																		8.00					8.00							
H5215	005	0	1	04	01	H5215_005_0	8	3	Preferred Brand	1	4	000101	1	2	100010110110101000000101				31		90	31		90	1	31		90							31		31		31	14										40.00		97.00						45.00		109.00						40.00		97.00																		40.00					40.00			40.00				
H5215	005	0	1	04	01	H5215_005_0	8	4	Non-Preferred Brand	1	4	100000	1	2	100010110110101000000001				31		90	31		90	1	31		90							31				31	14										70.00		189.00						75.00		203.00						70.00		189.00																		70.00								70.00				
H5215	005	0	1	04	01	H5215_005_0	8	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				31			31				31									31		31		31	14													484.00	33							484.00	33							33																			33				33			33			
H5215	005	0	1	04	01	H5215_005_0	8	1	Preferred Generic	3	4	001000	1	2	000010110110101000000100				31		90	31		90	1	31		90							31		31													1.00		2.00						3.00		8.00						1.00		2.00																		1.00					1.00					1		
H5215	005	0	1	04	01	H5215_005_0	8	2	Non-Preferred Generic	3	4	001100	1	2	000010110110101000000100				31		90	31		90	1	31		90							31		31													9.00		21.00						14.00		34.00						9.00		21.00																		9.00					9.00					1		
H5215	005	0	1	04	01	H5215_005_0	8	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				31		90	31		90	1	31		90							31		31													1.00		2.00						3.00		8.00						1.00		2.00																		1.00					1.00							
H5215	007	0	1	04	01	H5215_007_0	9	5	Specialty Tier	1	3	010010		1	100010010010100000000101				31			31				31									31		31		31	14													592.00	33							592.00	33							33																			33				33			33			
H5215	007	0	1	04	01	H5215_007_0	9	1	Preferred Generic	1	3	001000		2	000010110110101000000100				31		90	31		90	1	31		90							31		31													1.00		3.00						3.00		8.00						1.00		3.00																		1.00					1.00							
H5215	007	0	1	04	01	H5215_007_0	9	2	Non-Preferred Generic	1	3	001100		2	000010110110101000000100				31		90	31		90	1	31		90							31		31													10.00		20.00						13.00		26.00						10.00		20.00																		10.00					10.00							
H5215	007	0	1	04	01	H5215_007_0	9	3	Preferred Brand	1	3	000101		2	100010110110101000000101				31		90	31		90	1	31		90							31		31		31	14										42.00		105.00						45.00		115.00						42.00		105.00																		42.00					42.00			42.00				
H5215	007	0	1	04	01	H5215_007_0	9	4	Non-Preferred Brand	1	3	100000		2	100010110110101000000001				31		90	31		90	1	31		90							31				31	14										93.00		265.00						95.00		273.00						93.00		265.00																		93.00								93.00				
H5215	008	0	1	04	01	H5215_008_0	9	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				31			31				31									31		31		31	14													635.00	33							635.00	33							33																			33				33			33			
H5215	008	0	1	04	01	H5215_008_0	9	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				31		90	31		90	1	31		90							31		31													1.00		2.00						3.00		8.00						1.00		2.00																		1.00					1.00							
H5215	008	0	1	04	01	H5215_008_0	9	2	Non-Preferred Generic	1	4	001100	1	2	000010110110101000000100				31		90	31		90	1	31		90							31		31													8.00		20.00						13.00		33.00						8.00		20.00																		8.00					8.00							
H5215	008	0	1	04	01	H5215_008_0	9	3	Preferred Brand	1	4	000101	1	2	100010110110101000000101				31		90	31		90	1	31		90							31		31		31	14										40.00		97.00						45.00		109.00						40.00		97.00																		40.00					40.00			40.00				
H5215	008	0	1	04	01	H5215_008_0	9	4	Non-Preferred Brand	1	4	100000	1	2	100010110110101000000001				31		90	31		90	1	31		90							31				31	14										70.00		189.00						75.00		203.00						70.00		189.00																		70.00								70.00				
H5216	001	0	1	04	01	H5216_001_0	4	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H5216	001	0	1	04	01	H5216_001_0	4	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		42.00		126.00																													42.00		116.00					42.00		126.00				42.00					42.00			42.00				
H5216	001	0	1	04	01	H5216_001_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00				
H5216	001	0	1	04	01	H5216_001_0	4	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					848.00	33																														33							33					33				33			33	2	3	
H5216	001	0	1	04	01	H5216_001_0	4	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H5216	001	0	1	04	01	H5216_001_0	4	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		42.00		126.00																													42.00		116.00					42.00		126.00				42.00					42.00			42.00		2	2	
H5216	001	0	1	04	01	H5216_001_0	4	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00		2	3	1
H5216	001	0	1	04	01	H5216_001_0	4	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					796.00	33																														33							33					33				33			33			
H5216	003	0	1	04	01	H5216_003_0	4	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H5216	003	0	1	04	01	H5216_003_0	4	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H5216	003	0	1	04	01	H5216_003_0	4	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H5216	003	0	1	04	01	H5216_003_0	4	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1190.00	33																														33							33					33				33			33	2	3	
H5216	003	0	1	04	01	H5216_003_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H5216	003	0	1	04	01	H5216_003_0	4	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H5216	003	0	1	04	01	H5216_003_0	4	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H5216	003	0	1	04	01	H5216_003_0	4	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1118.00	33																														33							33					33				33			33			
H5216	006	0	1	04	01	H5216_006_0	4	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					600.00	33																														33							33					33				33			33			
H5216	006	0	1	04	01	H5216_006_0	4	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H5216	006	0	1	04	01	H5216_006_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H5216	006	0	1	04	01	H5216_006_0	4	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		34.00		102.00																													34.00		92.00					34.00		102.00				34.00					34.00			34.00		2	2	
H5216	006	0	1	04	01	H5216_006_0	4	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		75.00		225.00																													75.00		215.00					75.00		225.00				75.00					75.00			75.00		2	3	
H5216	006	0	1	04	01	H5216_006_0	4	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					579.00	33																														33							33					33				33			33	2	3	
H5216	006	0	1	04	01	H5216_006_0	4	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		34.00		102.00																													34.00		92.00					34.00		102.00				34.00					34.00			34.00				
H5216	006	0	1	04	01	H5216_006_0	4	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		75.00		225.00																													75.00		215.00					75.00		225.00				75.00					75.00			75.00				
H5253	004	0	1	02	01	H5253_004_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															0.00							18.00				6.00					6.00							
H5253	004	0	1	02	01	H5253_004_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H5253	004	0	1	02	01	H5253_004_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H5253	004	0	1	02	01	H5253_004_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					474.00	33		33																														33							33			33				33			33			
H5253	004	0	1	02	01	H5253_004_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00							
H5253	011	0	1	02	01	H5253_011_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H5253	011	0	1	02	01	H5253_011_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H5253	011	0	1	02	01	H5253_011_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H5253	011	0	1	02	01	H5253_011_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H5253	011	0	1	02	01	H5253_011_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					371.00	33		33																														33							33			33				33			33			
H5253	028	0	1	02	01	H5253_028_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H5253	028	0	1	02	01	H5253_028_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H5253	028	0	1	02	01	H5253_028_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H5253	028	0	1	02	01	H5253_028_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H5253	028	0	1	02	01	H5253_028_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					288.00	33		33																														33							33			33				33			33			
H5253	030	0	1	02	01	H5253_030_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00							
H5253	030	0	1	02	01	H5253_030_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					5.00		15.00																															10.00							15.00				5.00					5.00							
H5253	030	0	1	02	01	H5253_030_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H5253	030	0	1	02	01	H5253_030_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H5253	030	0	1	02	01	H5253_030_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					478.00	33		33																														33							33			33				33			33			
H5253	031	0	1	01	01	H5253_031_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H5253	031	0	1	01	01	H5253_031_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					474.00	33		33																														33							33			33				33			33			
H5253	031	0	1	01	01	H5253_031_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H5253	031	0	1	01	01	H5253_031_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															0.00							18.00				6.00					6.00							
H5253	031	0	1	01	01	H5253_031_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00							
H5253	032	0	1	01	01	H5253_032_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H5253	032	0	1	01	01	H5253_032_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H5253	032	0	1	01	01	H5253_032_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H5253	032	0	1	01	01	H5253_032_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					371.00	33		33																														33							33			33				33			33			
H5253	032	0	1	01	01	H5253_032_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00							
H5262	001	0	1	01	01	H5262_001_0	3	1	Preferred Generic	1	3	001000		2	010100000010000000000100	30		90							1										30		31					8.00		24.00																																										8.00					8.00							
H5262	001	0	1	01	01	H5262_001_0	3	2	Non-Preferred Generic	1	3	000100		2	010100000010000000000100	30		90							1										30		31					30.00		90.00																																										30.00					30.00							
H5262	001	0	1	01	01	H5262_001_0	3	3	Preferred Brand	1	3	000001		2	110100000010000000000001	30		90							1										30				31	14		45.00		135.00																																										45.00								45.00				
H5262	001	0	1	01	01	H5262_001_0	3	4	Non-Preferred Brand	1	3	100000		2	110100000010000000000001	30		90							1										30				31	14		95.00		285.00																																										95.00								95.00				
H5262	001	0	1	01	01	H5262_001_0	3	5	Specialty Tier	1	3	010010		1	110100000010000000000101	30		90							1										30		31		31	14					172.31	31		31																																								31				31			31			
H5262	003	0	1	01	01	H5262_003_0	4	1	Preferred Generic	1	3	001000		2	010100000010000000000100	30		90							1										30		31					10.00		30.00																																										10.00					10.00							
H5262	003	0	1	01	01	H5262_003_0	4	2	Non-Preferred Generic	1	3	000100		2	010100000010000000000100	30		90							1										30		31					33.00		99.00																																										33.00					33.00							
H5262	003	0	1	01	01	H5262_003_0	4	3	Preferred Brand	1	3	000001		2	110100000010000000000001	30		90							1										30				31	14		45.00		135.00																																										45.00								45.00				
H5262	003	0	1	01	01	H5262_003_0	4	4	Non-Preferred Brand	1	3	100000		2	110100000010000000000001	30		90							1										30				31	14		95.00		285.00																																										95.00								95.00				
H5262	003	0	1	01	01	H5262_003_0	4	5	Specialty Tier	1	3	010010		1	110100000010000000000101	30		90							1										30		31		31	14					297.92	30		30																																								30				30			30			
H5291	001	0	1	01	01	H5291_001_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		89.00		267.00																													89.00		257.00					89.00		267.00				89.00					89.00			89.00				
H5291	001	0	1	01	01	H5291_001_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H5291	001	0	1	01	01	H5291_001_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H5291	001	0	1	01	01	H5291_001_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H5291	001	0	1	01	01	H5291_001_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H5291	001	0	1	01	01	H5291_001_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					645.00	33																														33							33					33				33			33			
H5291	001	0	1	01	01	H5291_001_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		89.00		267.00																													89.00		257.00					89.00		267.00				89.00					89.00			89.00		2	3	
H5291	001	0	1	01	01	H5291_001_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00		2	3	1
H5291	001	0	1	01	01	H5291_001_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H5291	001	0	1	01	01	H5291_001_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					846.00	33																														33							33					33				33			33	2	3	
H5291	002	0	1	01	01	H5291_002_0	4	5	Specialty Tier	3	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													702.00	25							712.00	25														25							25					25				25			25	2	3	
H5291	002	0	1	01	01	H5291_002_0	4	3	Preferred Brand	3	4	000101	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													18.00	15		15					32.00	25		25												15		15					25		25			25				25			25	2	2	
H5291	002	0	1	01	01	H5291_002_0	4	2	Non-Preferred Generic	3	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										3.00		9.00						9.00		27.00													0.00		0.00					9.00		27.00				9.00					9.00			9.00		2	3	
H5291	002	0	1	01	01	H5291_002_0	4	5	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													598.00	25							607.00	25														25							25					25				25			25			
H5291	002	0	1	01	01	H5291_002_0	4	4	Non-Preferred Brand	1	4	110000	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													80.00	30		30					82.00	43		43												30		30					43		43			43				43			43			
H5291	002	0	1	01	01	H5291_002_0	4	3	Preferred Brand	1	4	000101	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													13.00	15		15					23.00	25		25												15		15					25		25			25				25			25			
H5291	002	0	1	01	01	H5291_002_0	4	2	Non-Preferred Generic	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										3.00		9.00						9.00		27.00													0.00		0.00					9.00		27.00				9.00					9.00			9.00				
H5291	002	0	1	01	01	H5291_002_0	4	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										1.00		3.00						7.00		21.00													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H5291	002	0	1	01	01	H5291_002_0	4	4	Non-Preferred Brand	3	4	110000	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													112.00	30		30					114.00	43		43												30		30					43		43			43				43			43	2	3	
H5294	001	0	1	01	01	H5294_001_0	10	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							2			90							30				31	7		95.00		95.00																								95.00																		95.00								95.00				
H5294	001	0	1	01	01	H5294_001_0	10	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	7		45.00		45.00																								45.00																		45.00								45.00				
H5294	001	0	1	01	01	H5294_001_0	10	1	Generic	1	4	010000	1	2	010100000010001000000100	30		90							2			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H5294	001	0	1	01	01	H5294_001_0	10	4	Injectable Drugs	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	7		95.00		95.00																								95.00																		95.00								95.00				
H5302	003	0	1	02	01	H5302_003_0	13	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													3.00		9.00						4.00		12.00						3.00		4.50																		4.00					4.00							
H5302	003	0	1	02	01	H5302_003_0	13	2	Non-Preferred Generic	1	4	000100	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													18.00		54.00						22.00		66.00						18.00		36.00																		22.00					22.00							
H5302	003	0	1	02	01	H5302_003_0	13	3	Preferred Brand	1	4	000001	1	2	100010110110101000000001				30		90	30		90	2	30		90							30				31	14										45.00		135.00						45.00		135.00						45.00		112.50																		45.00								45.00				
H5302	003	0	1	02	01	H5302_003_0	13	4	Non-Preferred Brand	1	4	100100	1	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										85.00		255.00						90.00		270.00						85.00		212.50																		90.00					90.00			90.00				
H5302	003	0	1	02	01	H5302_003_0	13	5	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													794.24	33							794.24	33																										33				33			33			
H5302	006	0	1	02	01	H5302_006_0	13	5	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													608.99	33							608.99	33																										33				33			33			
H5302	006	0	1	02	01	H5302_006_0	13	4	Non-Preferred Brand	1	4	100100	1	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										85.00		255.00						90.00		270.00						85.00		212.50																		90.00					90.00			90.00				
H5302	006	0	1	02	01	H5302_006_0	13	3	Preferred Brand	1	4	000001	1	2	100010110110101000000001				30		90	30		90	2	30		90							30				31	14										45.00		135.00						45.00		135.00						45.00		112.50																		45.00								45.00				
H5302	006	0	1	02	01	H5302_006_0	13	2	Non-Preferred Generic	1	4	000100	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													18.00		54.00						22.00		66.00						18.00		36.00																		22.00					22.00							
H5302	006	0	1	02	01	H5302_006_0	13	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													3.00		9.00						4.00		12.00						3.00		4.50																		4.00					4.00							
H5302	008	0	1	01	01	H5302_008_0	12	4	Non-Preferred Brand	1	4	100100	1	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										85.00		255.00						90.00		270.00						85.00		212.50																		90.00					90.00			90.00				
H5302	008	0	1	01	01	H5302_008_0	12	5	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													910.34	33							910.34	33																										33				33			33			
H5302	008	0	1	01	01	H5302_008_0	12	3	Preferred Brand	1	4	000001	1	2	100010110110101000000001				30		90	30		90	2	30		90							30				31	14										45.00		135.00						45.00		135.00						45.00		112.50																		45.00								45.00				
H5302	008	0	1	01	01	H5302_008_0	12	2	Non-Preferred Generic	1	4	000100	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													18.00		54.00						22.00		66.00						18.00		36.00																		22.00					22.00							
H5302	008	0	1	01	01	H5302_008_0	12	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													3.00		9.00						4.00		12.00						3.00		4.50																		4.00					4.00							
H5378	010	0	1	04	01	H5378_010_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		80.00		200.00																													80.00		160.00					80.00		200.00				80.00								80.00				
H5378	010	0	1	04	01	H5378_010_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		40.00		100.00																													40.00		80.00					40.00		100.00				40.00								40.00				
H5378	010	0	1	04	01	H5378_010_0	6	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		7.00		17.50																													7.00		14.00					7.00		17.50				7.00					7.00			7.00				
H5378	010	0	1	04	01	H5378_010_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					2.00		5.00																													2.00		4.00					2.00		5.00				2.00					2.00							
H5378	010	0	1	04	01	H5378_010_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					500.00	33																														33							33					33				33			33			
H5378	016	0	1	04	01	H5378_016_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		95.00		237.50																													95.00		190.00					95.00		237.50				95.00								95.00				
H5378	016	0	1	04	01	H5378_016_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		45.00		112.50																													45.00		90.00					45.00		112.50				45.00								45.00				
H5378	016	0	1	04	01	H5378_016_0	6	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		12.00		30.00																													12.00		24.00					12.00		30.00				12.00					12.00			12.00				
H5378	016	0	1	04	01	H5378_016_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					5.00		12.50																													5.00		10.00					5.00		12.50				5.00					5.00							
H5378	016	0	1	04	01	H5378_016_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					435.00	29																														29							29					29				29			29			
H5378	183	0	1	04	01	H5378_183_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					5.00		12.50																													5.00		10.00					5.00		12.50				5.00					5.00							
H5378	183	0	1	04	01	H5378_183_0	6	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		12.00		30.00																													12.00		24.00					12.00		30.00				12.00					12.00			12.00				
H5378	183	0	1	04	01	H5378_183_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		45.00		112.50																													45.00		90.00					45.00		112.50				45.00								45.00				
H5378	183	0	1	04	01	H5378_183_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		95.00		237.50																													95.00		190.00					95.00		237.50				95.00								95.00				
H5378	183	0	1	04	01	H5378_183_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					435.00	29																														29							29					29				29			29			
H5378	184	0	1	04	01	H5378_184_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					435.00	29																														29							29					29				29			29			
H5378	184	0	1	04	01	H5378_184_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		95.00		237.50																													95.00		190.00					95.00		237.50				95.00								95.00				
H5378	184	0	1	04	01	H5378_184_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		45.00		112.50																													45.00		90.00					45.00		112.50				45.00								45.00				
H5378	184	0	1	04	01	H5378_184_0	9	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		12.00		30.00																													12.00		24.00					12.00		30.00				12.00					12.00			12.00				
H5378	184	0	1	04	01	H5378_184_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					5.00		12.50																													5.00		10.00					5.00		12.50				5.00					5.00							
H5378	188	0	1	04	01	H5378_188_0	6	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		7.00		17.50																													7.00		14.00					7.00		17.50				7.00					7.00			7.00				
H5378	188	0	1	04	01	H5378_188_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					2.00		5.00																													2.00		4.00					2.00		5.00				2.00					2.00							
H5378	188	0	1	04	01	H5378_188_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		40.00		100.00																													40.00		80.00					40.00		100.00				40.00								40.00				
H5378	188	0	1	04	01	H5378_188_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		80.00		200.00																													80.00		160.00					80.00		200.00				80.00								80.00				
H5378	188	0	1	04	01	H5378_188_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					500.00	33																														33							33					33				33			33			
H5378	190	0	1	04	01	H5378_190_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					435.00	29																														29							29					29				29			29			
H5378	190	0	1	04	01	H5378_190_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		95.00		237.50																													95.00		190.00					95.00		237.50				95.00								95.00				
H5378	190	0	1	04	01	H5378_190_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		45.00		112.50																													45.00		90.00					45.00		112.50				45.00								45.00				
H5378	190	0	1	04	01	H5378_190_0	6	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		12.00		30.00																													12.00		24.00					12.00		30.00				12.00					12.00			12.00				
H5378	190	0	1	04	01	H5378_190_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					5.00		12.50																													5.00		10.00					5.00		12.50				5.00					5.00							
H5378	194	0	1	04	01	H5378_194_0	6	2	Non-Preferred Generic	1	3	000110		2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		12.00		30.00																													12.00		24.00					12.00		30.00				12.00					12.00			12.00				
H5378	194	0	1	04	01	H5378_194_0	6	1	Preferred Generic	1	3	001000		2	010100000010000101101100	30		90							2				30		90	30		90	30		34					5.00		12.50																													5.00		10.00					5.00		12.50				5.00					5.00							
H5378	194	0	1	04	01	H5378_194_0	6	3	Preferred Brand	1	3	000001		2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		45.00		112.50																													45.00		90.00					45.00		112.50				45.00								45.00				
H5378	194	0	1	04	01	H5378_194_0	6	4	Non-Preferred Brand	1	3	100000		2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		95.00		237.50																													95.00		190.00					95.00		237.50				95.00								95.00				
H5378	194	0	1	04	01	H5378_194_0	6	5	Specialty Tier	1	3	010010		1	110000000010000100100101	30													30			30			30		34		34	14					435.00	29																														29							29					29				29			29			
H5378	199	0	1	04	01	H5378_199_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					500.00	33																														33							33					33				33			33			
H5378	199	0	1	04	01	H5378_199_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		80.00		200.00																													80.00		160.00					80.00		200.00				80.00								80.00				
H5378	199	0	1	04	01	H5378_199_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		40.00		100.00																													40.00		80.00					40.00		100.00				40.00								40.00				
H5378	199	0	1	04	01	H5378_199_0	6	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		7.00		17.50																													7.00		14.00					7.00		17.50				7.00					7.00			7.00				
H5378	199	0	1	04	01	H5378_199_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					2.00		5.00																													2.00		4.00					2.00		5.00				2.00					2.00							
H5378	200	0	1	04	01	H5378_200_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					500.00	33																														33							33					33				33			33			
H5378	200	0	1	04	01	H5378_200_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		80.00		200.00																													80.00		160.00					80.00		200.00				80.00								80.00				
H5378	200	0	1	04	01	H5378_200_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		40.00		100.00																													40.00		80.00					40.00		100.00				40.00								40.00				
H5378	200	0	1	04	01	H5378_200_0	6	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		7.00		17.50																													7.00		14.00					7.00		17.50				7.00					7.00			7.00				
H5378	200	0	1	04	01	H5378_200_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					2.00		5.00																													2.00		4.00					2.00		5.00				2.00					2.00							
H5404	001	0	1	01	01	H5404_001_0	6	1	Preferred Generic	3	4	001000	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14			0.00	0.00		0.00																					0.00	0.00	0.00	0.00																		0.00				0.00	0.00					1		
H5404	001	0	1	01	01	H5404_001_0	6	3	Preferred Brand	1	4	010001	1	2	110100000010111000000111	31		90							1	31	60	90							31		34	14	34	14		15.00		45.00																						15.00	30.00	45.00																		15.00					15.00			15.00				
H5404	001	0	1	01	01	H5404_001_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110100000010111000000001	31		90							1	31	60	90							31				34	14		60.00		180.00																						60.00	120.00	180.00																		60.00								60.00				
H5404	001	0	1	01	01	H5404_001_0	6	5	Specialty Tier	1	4	010010	1	1	110100000010111000000111	31		90							1	31	60	90							31		34	14	34	14					250.00	33		33																					33	33	33																	33				33			33			
H5404	001	0	1	01	01	H5404_001_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14				0.00		0.00																						0.00	0.00	0.00																		0.00					0.00							
H5404	001	0	1	01	01	H5404_001_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14				0.00		0.00																						0.00	0.00	0.00																		0.00					0.00							
H5404	001	0	1	01	01	H5404_001_0	6	2	Non-Preferred Generic	3	4	000100	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14			0.00	0.00		0.00																					0.00	0.00	0.00	0.00																		0.00				0.00	0.00					1		
H5404	034	0	1	01	01	H5404_034_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110100000010111000000001	31		90							1	31	60	90							31				34	14		60.00		180.00																						60.00	120.00	180.00																		60.00								60.00				
H5404	034	0	1	01	01	H5404_034_0	6	5	Specialty Tier	1	4	010010	1	1	110100000010111000000111	31		90							1	31	60	90							31		34	14	34	14					250.00	33		33																					33	33	33																	33				33			33			
H5404	034	0	1	01	01	H5404_034_0	6	1	Preferred Generic	3	4	001000	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14			0.00	0.00		0.00																					0.00	0.00	0.00	0.00																		0.00				0.00	0.00					1		
H5404	034	0	1	01	01	H5404_034_0	6	2	Non-Preferred Generic	3	4	000100	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14			0.00	0.00		0.00																					0.00	0.00	0.00	0.00																		0.00				0.00	0.00					1		
H5404	034	0	1	01	01	H5404_034_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14				0.00		0.00																						0.00	0.00	0.00																		0.00					0.00							
H5404	034	0	1	01	01	H5404_034_0	6	3	Preferred Brand	1	4	010001	1	2	110100000010111000000111	31		90							1	31	60	90							31		34	14	34	14		10.00		30.00																						10.00	20.00	30.00																		10.00					10.00			10.00				
H5404	034	0	1	01	01	H5404_034_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14				0.00		0.00																						0.00	0.00	0.00																		0.00					0.00							
H5404	086	0	1	01	01	H5404_086_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14				15.00		45.00																						15.00	30.00	30.00																		15.00					15.00							
H5404	086	0	1	01	01	H5404_086_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14				6.00		18.00																						6.00	12.00	12.00																		6.00					6.00							
H5404	086	0	1	01	01	H5404_086_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000010111000000001	31		90							1	31	60	90							31				34	14		95.00		285.00																						95.00	190.00	285.00																		95.00								95.00				
H5404	086	0	1	01	01	H5404_086_0	9	3	Preferred Brand	1	4	010001	1	2	110100000010111000000111	31		90							1	31	60	90							31		34	14	34	14		45.00		135.00																						45.00	90.00	135.00																		45.00					45.00			45.00				
H5404	086	0	1	01	01	H5404_086_0	9	5	Specialty Tier	1	4	010010	1	1	110100000010111000000111	31		90							1	31	60	90							31		34	14	34	14					250.00	33		33																					33	33	33																	33				33			33			
H5404	135	0	1	01	01	H5404_135_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14				0.00		0.00																						0.00	0.00	0.00																		0.00					0.00							
H5404	135	0	1	01	01	H5404_135_0	6	5	Specialty Tier	1	4	010010	1	1	110100000010111000000111	31		90							1	31	60	90							31		34	14	34	14					100.00	33		33																					33	33	33																	33				33			33			
H5404	135	0	1	01	01	H5404_135_0	6	1	Preferred Generic	3	4	001000	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14				0.00		0.00																						0.00	0.00	0.00																		0.00					0.00					1		
H5404	135	0	1	01	01	H5404_135_0	6	2	Non-Preferred Generic	3	4	000100	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14				0.00		0.00																						0.00	0.00	0.00																		0.00					0.00					1		
H5404	135	0	1	01	01	H5404_135_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14				0.00		0.00																						0.00	0.00	0.00																		0.00					0.00							
H5404	135	0	1	01	01	H5404_135_0	6	3	Preferred Brand	1	4	010001	1	2	110100000010111000000111	31		90							1	31	60	90							31		34	14	34	14		20.00		60.00																						20.00	40.00	60.00																		20.00					20.00			20.00				
H5404	135	0	1	01	01	H5404_135_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110100000010111000000001	31		90							1	31	60	90							31				34	14		50.00		150.00																						50.00	100.00	150.00																		50.00								50.00				
H5404	136	0	1	01	01	H5404_136_0	6	2	Non-Preferred Generic	3	4	000100	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14				0.00		0.00																						0.00	0.00	0.00																		0.00					0.00					1		
H5404	136	0	1	01	01	H5404_136_0	6	1	Preferred Generic	3	4	001000	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14				0.00		0.00																						0.00	0.00	0.00																		0.00					0.00					1		
H5404	136	0	1	01	01	H5404_136_0	6	5	Specialty Tier	1	4	010010	1	1	110100000010111000000111	31		90							1	31	60	90							31		34	14	34	14					100.00	33		33																					33	33	33																	33				33			33			
H5404	136	0	1	01	01	H5404_136_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110100000010111000000001	31		90							1	31	60	90							31				34	14		95.00		285.00																						95.00	190.00	285.00																		95.00								95.00				
H5404	136	0	1	01	01	H5404_136_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14				0.00		0.00																						0.00	0.00	0.00																		0.00					0.00							
H5404	136	0	1	01	01	H5404_136_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14				0.00		0.00																						0.00	0.00	0.00																		0.00					0.00							
H5404	136	0	1	01	01	H5404_136_0	6	3	Preferred Brand	1	4	010001	1	2	110100000010111000000111	31		90							1	31	60	90							31		34	14	34	14		45.00		135.00																						45.00	90.00	135.00																		45.00					45.00			45.00				
H5404	137	0	1	01	01	H5404_137_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110100000010111000000001	31		90							1	31	60	90							31				34	14		50.00		150.00																						50.00	100.00	150.00																		50.00								50.00				
H5404	137	0	1	01	01	H5404_137_0	6	5	Specialty Tier	1	4	010010	1	1	110100000010111000000111	31		90							1	31	60	90							31		34	14	34	14					100.00	33		33																					33	33	33																	33				33			33			
H5404	137	0	1	01	01	H5404_137_0	6	1	Preferred Generic	3	4	001000	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14				0.00		0.00																						0.00	0.00	0.00																		0.00					0.00					1		
H5404	137	0	1	01	01	H5404_137_0	6	2	Non-Preferred Generic	3	4	000100	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14				0.00		0.00																						0.00	0.00	0.00																		0.00					0.00					1		
H5404	137	0	1	01	01	H5404_137_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14				0.00		0.00																						0.00	0.00	0.00																		0.00					0.00							
H5404	137	0	1	01	01	H5404_137_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14				0.00		0.00																						0.00	0.00	0.00																		0.00					0.00							
H5404	137	0	1	01	01	H5404_137_0	6	3	Preferred Brand	1	4	010001	1	2	110100000010111000000111	31		90							1	31	60	90							31		34	14	34	14		20.00		60.00																						20.00	40.00	60.00																		20.00					20.00			20.00				
H5404	143	0	1	01	01	H5404_143_0	7	2	Non-Preferred Generic	3	4	000100	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14				0.00		0.00																						0.00	0.00	0.00																		0.00					0.00					1		
H5404	143	0	1	01	01	H5404_143_0	7	1	Preferred Generic	3	4	001000	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14				0.00		0.00																						0.00	0.00	0.00																		0.00					0.00					1		
H5404	143	0	1	01	01	H5404_143_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010111000000111	31		90							1	31	60	90							31		34	14	34	14					250.00	33		33																					33	33	33																	33				33			33			
H5404	143	0	1	01	01	H5404_143_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14				0.00		0.00																						0.00	0.00	0.00																		0.00					0.00							
H5404	143	0	1	01	01	H5404_143_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010111000000111	31		90							1	31	60	90							31		34	14	34	14		0.00		0.00																						0.00	0.00	0.00																		0.00					0.00			0.00				
H5404	143	0	1	01	01	H5404_143_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110100000010111000000001	31		90							1	31	60	90							31				34	14		60.00		180.00																						60.00	120.00	180.00																		60.00								60.00				
H5404	143	0	1	01	01	H5404_143_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14				0.00		0.00																						0.00	0.00	0.00																		0.00					0.00							
H5404	144	0	1	01	01	H5404_144_0	6	3	Preferred Brand	1	4	010001	1	2	110100000010111000000111	31		90							1	31	60	90							31		34	14	34	14		45.00		135.00																						45.00	90.00	135.00																		45.00					45.00			45.00				
H5404	144	0	1	01	01	H5404_144_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14				15.00		45.00																						15.00	30.00	30.00																		15.00					15.00							
H5404	144	0	1	01	01	H5404_144_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14				4.00		12.00																						4.00	8.00	8.00																		4.00					4.00							
H5404	144	0	1	01	01	H5404_144_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110100000010111000000001	31		90							1	31	60	90							31				34	14		95.00		285.00																						95.00	190.00	285.00																		95.00								95.00				
H5404	144	0	1	01	01	H5404_144_0	6	5	Specialty Tier	1	4	010010	1	1	110100000010111000000111	31		90							1	31	60	90							31		34	14	34	14					250.00	33		33																					33	33	33																	33				33			33			
H5410	001	0	1	01	01	H5410_001_0	8	1	Generic	3	4	010000	3	2	000010010010000000000100				30			30													30		31													0.00								5.00																												5.00					5.00					1		
H5410	001	0	1	01	01	H5410_001_0	8	1	Generic	1	4	010000	3	2	000010010010000000000100				30			30													30		31													0.00								5.00																												5.00					5.00							
H5410	001	0	1	01	01	H5410_001_0	8	2	Brand	1	4	000010	1	2	100010010010000000000001				30			30													30				31	14										0.00								10.00																												10.00								10.00				
H5410	001	0	1	01	01	H5410_001_0	8	3	Specialty Tier	1	4	000010	1	1	100010010010000000000001				30			30													30				31	14													177.45	33							177.45	33																										33							33			
H5410	005	0	1	01	01	H5410_005_0	7	1	Preferred Generic	3	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					3.00	6.00	9.00																								0.00																		3.00					3.00					1		
H5410	005	0	1	01	01	H5410_005_0	7	5	Specialty Tier	1	4	010010	1	1	111100000010001000000101	30	60	90							2			90							30		31		31	14					68.23	33	33	33																							33																	33				33			33			
H5410	005	0	1	01	01	H5410_005_0	7	4	Non-Preferred Brand	1	4	100100	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		85.00	170.00	255.00																								245.00																		85.00					85.00			85.00				
H5410	005	0	1	01	01	H5410_005_0	7	3	Preferred Brand	1	4	000001	1	2	111100000010001000000001	30	60	90							2			90							30				31	14		45.00	90.00	135.00																								125.00																		45.00								45.00				
H5410	005	0	1	01	01	H5410_005_0	7	2	Non-Preferred Generic	1	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		10.00	20.00	30.00																								21.00																		10.00					10.00			10.00				
H5410	005	0	1	01	01	H5410_005_0	7	1	Preferred Generic	1	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					3.00	6.00	9.00																								0.00																		3.00					3.00							
H5410	005	0	1	01	01	H5410_005_0	7	2	Non-Preferred Generic	3	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		10.00	20.00	30.00																								21.00																		10.00					10.00			10.00		2	2	
H5410	012	0	1	02	01	H5410_012_0	7	1	Preferred Generic	1	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					3.00	6.00	9.00																								0.00																		3.00					3.00							
H5410	012	0	1	02	01	H5410_012_0	7	2	Non-Preferred Generic	1	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		6.00	12.00	18.00																								9.00																		6.00					6.00			6.00				
H5410	012	0	1	02	01	H5410_012_0	7	3	Preferred Brand	1	4	000001	1	2	111100000010001000000001	30	60	90							2			90							30				31	14		45.00	90.00	135.00																								125.00																		45.00								45.00				
H5410	012	0	1	02	01	H5410_012_0	7	4	Non-Preferred Brand	1	4	100100	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		85.00	170.00	255.00																								245.00																		85.00					85.00			85.00				
H5410	012	0	1	02	01	H5410_012_0	7	5	Specialty Tier	1	4	010010	1	1	111100000010001000000101	30	60	90							2			90							30		31		31	14					317.63	33	33	33																							33																	33				33			33			
H5410	012	0	1	02	01	H5410_012_0	7	1	Preferred Generic	3	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					3.00	6.00	9.00																								0.00																		3.00					3.00					1		
H5410	012	0	1	02	01	H5410_012_0	7	2	Non-Preferred Generic	3	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		6.00	12.00	18.00																								9.00																		6.00					6.00			6.00		2	2	
H5410	017	0	1	01	01	H5410_017_0	6	2	Non-Preferred Generic	3	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		10.00	20.00	30.00																								21.00																		10.00					10.00			10.00		2	2	
H5410	017	0	1	01	01	H5410_017_0	6	1	Preferred Generic	3	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					3.00	6.00	9.00																								0.00																		3.00					3.00					1		
H5410	017	0	1	01	01	H5410_017_0	6	5	Specialty Tier	1	4	010010	1	1	111100000010001000000101	30	60	90							2			90							30		31		31	14					322.26	33	33	33																							33																	33				33			33			
H5410	017	0	1	01	01	H5410_017_0	6	4	Non-Preferred Brand	1	4	100100	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		85.00	170.00	255.00																								245.00																		85.00					85.00			85.00				
H5410	017	0	1	01	01	H5410_017_0	6	3	Preferred Brand	1	4	000001	1	2	111100000010001000000001	30	60	90							2			90							30				31	14		45.00	90.00	135.00																								125.00																		45.00								45.00				
H5410	017	0	1	01	01	H5410_017_0	6	1	Preferred Generic	1	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					3.00	6.00	9.00																								0.00																		3.00					3.00							
H5410	017	0	1	01	01	H5410_017_0	6	2	Non-Preferred Generic	1	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		10.00	20.00	30.00																								21.00																		10.00					10.00			10.00				
H5410	018	0	1	02	01	H5410_018_0	6	1	Preferred Generic	1	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					3.00	6.00	9.00																								0.00																		3.00					3.00							
H5410	018	0	1	02	01	H5410_018_0	6	2	Non-Preferred Generic	1	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		6.00	12.00	18.00																								9.00																		6.00					6.00			6.00				
H5410	018	0	1	02	01	H5410_018_0	6	3	Preferred Brand	1	4	000001	1	2	111100000010001000000001	30	60	90							2			90							30				31	14		45.00	90.00	135.00																								125.00																		45.00								45.00				
H5410	018	0	1	02	01	H5410_018_0	6	4	Non-Preferred Brand	1	4	100100	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		85.00	170.00	255.00																								245.00																		85.00					85.00			85.00				
H5410	018	0	1	02	01	H5410_018_0	6	5	Specialty Tier	1	4	010010	1	1	111100000010001000000101	30	60	90							2			90							30		31		31	14					322.39	33	33	33																							33																	33				33			33			
H5410	018	0	1	02	01	H5410_018_0	6	1	Preferred Generic	3	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					3.00	6.00	9.00																								0.00																		3.00					3.00					1		
H5410	018	0	1	02	01	H5410_018_0	6	2	Non-Preferred Generic	3	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		6.00	12.00	18.00																								9.00																		6.00					6.00			6.00		2	2	
H5414	009	0	1	01	01	H5414_009_0	5	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H5414	009	0	1	01	01	H5414_009_0	5	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					433.10	33	33	33																												33	33	33					33	33	33				33			33			33			
H5414	009	0	1	01	01	H5414_009_0	5	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H5414	009	0	1	01	01	H5414_009_0	5	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H5414	009	0	1	01	01	H5414_009_0	5	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					7.00	14.00	21.00																													7.00	14.00	14.00					7.00	14.00	21.00					7.00				7.00							
H5414	019	0	1	01	01	H5414_019_0	5	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H5414	019	0	1	01	01	H5414_019_0	5	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					7.00	14.00	21.00																													7.00	14.00	14.00					7.00	14.00	21.00					7.00				7.00							
H5414	019	0	1	01	01	H5414_019_0	5	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					389.77	33	33	33																												33	33	33					33	33	33				33			33			33			
H5414	019	0	1	01	01	H5414_019_0	5	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H5414	019	0	1	01	01	H5414_019_0	5	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H5414	023	0	1	01	01	H5414_023_0	7	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H5414	023	0	1	01	01	H5414_023_0	7	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H5414	023	0	1	01	01	H5414_023_0	7	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					7.00	14.00	21.00																													7.00	14.00	14.00					7.00	14.00	21.00					7.00				7.00							
H5414	023	0	1	01	01	H5414_023_0	7	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					326.55	33	33	33																												33	33	33					33	33	33				33			33			33			
H5414	023	0	1	01	01	H5414_023_0	7	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H5415	056	0	1	04	01	H5415_056_0	5	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H5415	056	0	1	04	01	H5415_056_0	5	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		43.00		129.00																													43.00		119.00					43.00		129.00				43.00					43.00			43.00		2	2	
H5415	056	0	1	04	01	H5415_056_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H5415	056	0	1	04	01	H5415_056_0	5	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					677.00	33																														33							33					33				33			33			
H5415	056	0	1	04	01	H5415_056_0	5	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H5415	056	0	1	04	01	H5415_056_0	5	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		43.00		129.00																													43.00		119.00					43.00		129.00				43.00					43.00			43.00				
H5415	056	0	1	04	01	H5415_056_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H5415	056	0	1	04	01	H5415_056_0	5	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					855.00	33																														33							33					33				33			33	2	3	
H5415	066	0	1	04	01	H5415_066_0	5	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1413.00	33																														33							33					33				33			33	2	3	
H5415	066	0	1	04	01	H5415_066_0	5	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H5415	066	0	1	04	01	H5415_066_0	5	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H5415	066	0	1	04	01	H5415_066_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00		2	3	
H5415	066	0	1	04	01	H5415_066_0	5	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1206.00	33																														33							33					33				33			33			
H5415	066	0	1	04	01	H5415_066_0	5	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H5415	066	0	1	04	01	H5415_066_0	5	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H5415	066	0	1	04	01	H5415_066_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H5415	067	0	1	04	01	H5415_067_0	5	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H5415	067	0	1	04	01	H5415_067_0	5	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H5415	067	0	1	04	01	H5415_067_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00		2	3	1
H5415	067	0	1	04	01	H5415_067_0	5	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					870.00	33																														33							33					33				33			33			
H5415	067	0	1	04	01	H5415_067_0	5	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H5415	067	0	1	04	01	H5415_067_0	5	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H5415	067	0	1	04	01	H5415_067_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H5415	067	0	1	04	01	H5415_067_0	5	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					977.00	33																														33							33					33				33			33	2	3	
H5415	068	0	1	04	01	H5415_068_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H5415	068	0	1	04	01	H5415_068_0	5	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H5415	068	0	1	04	01	H5415_068_0	5	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H5415	068	0	1	04	01	H5415_068_0	5	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					852.00	33																														33							33					33				33			33			
H5415	068	0	1	04	01	H5415_068_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00		2	3	1
H5415	068	0	1	04	01	H5415_068_0	5	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H5415	068	0	1	04	01	H5415_068_0	5	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					960.00	33																														33							33					33				33			33	2	3	
H5415	068	0	1	04	01	H5415_068_0	5	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H5415	069	0	1	04	01	H5415_069_0	5	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H5415	069	0	1	04	01	H5415_069_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H5415	069	0	1	04	01	H5415_069_0	5	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H5415	069	0	1	04	01	H5415_069_0	5	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					860.00	33																														33							33					33				33			33			
H5415	069	0	1	04	01	H5415_069_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00		2	3	1
H5415	069	0	1	04	01	H5415_069_0	5	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H5415	069	0	1	04	01	H5415_069_0	5	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H5415	069	0	1	04	01	H5415_069_0	5	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					969.00	33																														33							33					33				33			33	2	3	
H5415	070	0	1	04	01	H5415_070_0	5	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H5415	070	0	1	04	01	H5415_070_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H5415	070	0	1	04	01	H5415_070_0	5	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					946.00	33																														33							33					33				33			33	2	3	
H5415	070	0	1	04	01	H5415_070_0	5	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H5415	070	0	1	04	01	H5415_070_0	5	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H5415	070	0	1	04	01	H5415_070_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00		2	3	1
H5415	070	0	1	04	01	H5415_070_0	5	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					839.00	33																														33							33					33				33			33			
H5415	070	0	1	04	01	H5415_070_0	5	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H5416	002	0	1	01	01	H5416_002_0	10	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1378.00	33																														33							33					33				33			33	2	3	
H5416	002	0	1	01	01	H5416_002_0	10	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H5416	002	0	1	01	01	H5416_002_0	10	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H5416	002	0	1	01	01	H5416_002_0	10	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H5416	002	0	1	01	01	H5416_002_0	10	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					169.00	33																														33							33					33				33			33			
H5416	002	0	1	01	01	H5416_002_0	10	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H5416	002	0	1	01	01	H5416_002_0	10	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H5416	002	0	1	01	01	H5416_002_0	10	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H5416	004	0	1	01	01	H5416_004_0	10	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H5416	004	0	1	01	01	H5416_004_0	10	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					217.00	33																														33							33					33				33			33			
H5416	004	0	1	01	01	H5416_004_0	10	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H5416	004	0	1	01	01	H5416_004_0	10	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H5416	004	0	1	01	01	H5416_004_0	10	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					2361.00	33																														33							33					33				33			33	2	3	
H5416	004	0	1	01	01	H5416_004_0	10	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H5416	004	0	1	01	01	H5416_004_0	10	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H5416	004	0	1	01	01	H5416_004_0	10	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H5416	009	0	1	01	01	H5416_009_0	8	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H5416	009	0	1	01	01	H5416_009_0	8	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H5416	009	0	1	01	01	H5416_009_0	8	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H5416	009	0	1	01	01	H5416_009_0	8	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					134.00	33																														33							33					33				33			33			
H5416	009	0	1	01	01	H5416_009_0	8	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H5416	009	0	1	01	01	H5416_009_0	8	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H5416	009	0	1	01	01	H5416_009_0	8	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H5416	009	0	1	01	01	H5416_009_0	8	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					3088.00	33																														33							33					33				33			33	2	3	
H5416	016	0	1	01	01	H5416_016_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H5416	016	0	1	01	01	H5416_016_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		11.00		33.00																													0.00		0.00					11.00		33.00				11.00					11.00			11.00				
H5416	016	0	1	01	01	H5416_016_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H5416	016	0	1	01	01	H5416_016_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H5416	016	0	1	01	01	H5416_016_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					774.00	33																														33							33					33				33			33			
H5416	016	0	1	01	01	H5416_016_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H5416	016	0	1	01	01	H5416_016_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		11.00		33.00																													0.00		0.00					11.00		33.00				11.00					11.00			11.00		2	2	
H5416	016	0	1	01	01	H5416_016_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H5416	016	0	1	01	01	H5416_016_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H5416	016	0	1	01	01	H5416_016_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					2612.00	33																														33							33					33				33			33	2	3	
H5416	018	0	1	01	01	H5416_018_0	8	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H5416	018	0	1	01	01	H5416_018_0	8	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H5416	018	0	1	01	01	H5416_018_0	8	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H5416	018	0	1	01	01	H5416_018_0	8	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					3872.00	33																														33							33					33				33			33	2	3	
H5416	018	0	1	01	01	H5416_018_0	8	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H5416	018	0	1	01	01	H5416_018_0	8	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H5416	018	0	1	01	01	H5416_018_0	8	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H5416	018	0	1	01	01	H5416_018_0	8	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H5416	018	0	1	01	01	H5416_018_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					462.00	33																														33							33					33				33			33			
H5416	018	0	1	01	01	H5416_018_0	8	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H5416	020	0	1	01	01	H5416_020_0	8	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H5416	020	0	1	01	01	H5416_020_0	8	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H5416	020	0	1	01	01	H5416_020_0	8	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		89.00		267.00																													89.00		257.00					89.00		267.00				89.00					89.00			89.00				
H5416	020	0	1	01	01	H5416_020_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					265.00	33																														33							33					33				33			33			
H5416	020	0	1	01	01	H5416_020_0	8	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		1.00		3.00																													0.00		0.00					1.00		3.00				1.00					1.00			1.00				
H5416	020	0	1	01	01	H5416_020_0	8	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H5416	020	0	1	01	01	H5416_020_0	8	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H5416	020	0	1	01	01	H5416_020_0	8	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		89.00		267.00																													89.00		257.00					89.00		267.00				89.00					89.00			89.00		2	3	
H5416	020	0	1	01	01	H5416_020_0	8	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					923.00	33																														33							33					33				33			33	2	3	
H5416	020	0	1	01	01	H5416_020_0	8	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		1.00		3.00																													0.00		0.00					1.00		3.00				1.00					1.00			1.00		2	3	1
H5416	021	0	1	01	01	H5416_021_0	8	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H5416	021	0	1	01	01	H5416_021_0	8	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H5416	021	0	1	01	01	H5416_021_0	8	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H5416	021	0	1	01	01	H5416_021_0	8	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					2606.00	33																														33							33					33				33			33	2	3	
H5416	021	0	1	01	01	H5416_021_0	8	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H5416	021	0	1	01	01	H5416_021_0	8	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H5416	021	0	1	01	01	H5416_021_0	8	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H5416	021	0	1	01	01	H5416_021_0	8	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	1
H5416	021	0	1	01	01	H5416_021_0	8	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H5416	021	0	1	01	01	H5416_021_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					673.00	33																														33							33					33				33			33			
H5420	001	0	1	01	01	H5420_001_0	9	1	Generic	1	4	010000	3	2	010000000010000000000100	30																			30		31					0.00																																												0.00					0.00							
H5420	001	0	1	01	01	H5420_001_0	9	3	Non-Preferred Brand	1	4	100000	1	2	110000000010000000000001	30																			30				31	14		20.00																																												20.00								20.00				
H5420	001	0	1	01	01	H5420_001_0	9	2	Preferred Brand	1	4	000001	3	2	110000000010000000000001	30																			30				31	14		5.00																																												5.00								5.00				
H5420	001	0	1	01	01	H5420_001_0	9	4	Specialty Tier	1	4	010010	1	1	110000000010000000000111	30																			30		31	14	31	14					477.38	25																																										25				25			25			
H5420	001	0	1	01	01	H5420_001_0	9	1	Generic	3	4	010000	3	2	010000000010000000000100	30																			30		31					0.00																																												0.00				0.00	0.00					1		
H5420	003	0	1	01	01	H5420_003_0	10	1	Generic	1	4	010000	3	2	010000000010000000000110	30																			30		31	14			0.00	0.00																																												0.00				0.00	0.00							
H5420	003	0	1	01	01	H5420_003_0	10	2	Preferred Brand	1	4	000001	3	2	110000000010000000000001	30																			30				31	14		30.00																																												30.00							0.97	30.00				
H5420	003	0	1	01	01	H5420_003_0	10	3	Non-Preferred Brand	1	4	100000	1	2	110000000010000000000001	30																			30				31	14		50.00																																												50.00							1.50	50.00				
H5420	003	0	1	01	01	H5420_003_0	10	1	Generic	3	4	010000	3	2	010000000010000000000110	30																			30		31	14			0.00	0.00																																												0.00					0.00					1		
H5420	003	0	1	01	01	H5420_003_0	10	4	Specialty Tier	1	4	010010	1	1	110000000010000000000111	30																			30		31	14	31	14					497.40	33																																										33				33			33			
H5420	006	0	1	01	01	H5420_006_0	9	1	Generic	1	4	010000	3	2	010000000010000000000100	30																			30		31					0.00																																												0.00					0.00							
H5420	006	0	1	01	01	H5420_006_0	9	1	Generic	3	4	010000	3	2	010000000010000000000100	30																			30		31					0.00																																												0.00					0.00					1		
H5420	006	0	1	01	01	H5420_006_0	9	4	Specialty Tier	1	4	010010	1	1	110000000010000000000111	30																			30		31	14	31	14					637.64	25																																										25				25			25			
H5420	006	0	1	01	01	H5420_006_0	9	3	Non-Preferred Brand	1	4	100000	1	1	110000000010000000000001	30																			30				31	14					66.15	35																																										35							35			
H5420	006	0	1	01	01	H5420_006_0	9	2	Preferred Brand	1	4	000001	3	1	110000000010000000000001	30																			30				31	14					43.11	25																																										25							25			
H5420	009	0	1	01	01	H5420_009_0	9	4	Specialty Tier	1	4	010010	1	1	110000000010000000000111	30																			30		31	14	31	14					690.80	33																																										33				33			33			
H5420	009	0	1	01	01	H5420_009_0	9	3	Non-Preferred Brand	1	4	100000	1	2	110000000010000000000001	30																			30				31	14		40.00																																												40.00								40.00				
H5420	009	0	1	01	01	H5420_009_0	9	1	Generic	1	4	010000	3	2	010000000010000000000100	30																			30		31					0.00																																												0.00					0.00							
H5420	009	0	1	01	01	H5420_009_0	9	2	Preferred Brand	1	4	000001	3	2	110000000010000000000001	30																			30				31	14		25.00																																												25.00								25.00				
H5420	010	0	1	01	01	H5420_010_0	9	4	Specialty Tier	1	4	010010	1	1	110000000010000000000111	30																			30		31	14	31	14					471.07	25																																										25				25			25			
H5420	010	0	1	01	01	H5420_010_0	9	3	Non-Preferred Brand	1	4	100000	1	2	110000000010000000000001	30																			30				31	14		20.00																																												20.00								20.00				
H5420	010	0	1	01	01	H5420_010_0	9	2	Preferred Brand	1	4	000001	3	2	110000000010000000000001	30																			30				31	14		5.00																																												5.00								5.00				
H5420	010	0	1	01	01	H5420_010_0	9	1	Generic	1	4	010000	3	2	010000000010000000000100	30																			30		31					0.00																																												0.00					0.00							
H5420	010	0	1	01	01	H5420_010_0	9	1	Generic	3	4	010000	3	2	010000000010000000000100	30																			30		31					0.00																																												0.00				0.00	0.00					1		
H5421	065	0	1	09	04	H5421_065_0	7	4	Non-Preferred Brand	1	3	100000		2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		92.00		230.00																													92.00		184.00					92.00		230.00				92.00								92.00				
H5421	065	0	1	09	04	H5421_065_0	7	3	Preferred Brand	1	3	000001		2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		45.00		112.50																													45.00		90.00					45.00		112.50				45.00								45.00				
H5421	065	0	1	09	04	H5421_065_0	7	2	Non-Preferred Generic	1	3	000110		2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		12.00		30.00																													12.00		24.00					12.00		30.00				12.00					12.00			12.00				
H5421	065	0	1	09	04	H5421_065_0	7	1	Preferred Generic	1	3	001000		2	010100000010000101101100	30		90							2				30		90	30		90	30		34					5.00		12.50																													5.00		10.00					5.00		12.50				5.00					5.00							
H5421	065	0	1	09	04	H5421_065_0	7	5	Specialty Tier	1	3	010010		1	110000000010000100100101	30													30			30			30		34		34	14					375.00	25																														25							25					25				25			25			
H5421	067	0	1	09	04	H5421_067_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		40.00		100.00																													40.00		80.00					40.00		100.00				40.00								40.00				
H5421	067	0	1	09	04	H5421_067_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					2.00		5.00																													2.00		4.00					2.00		5.00				2.00					2.00							
H5421	067	0	1	09	04	H5421_067_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		80.00		200.00																													80.00		160.00					80.00		200.00				80.00								80.00				
H5421	067	0	1	09	04	H5421_067_0	7	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		7.00		17.50																													7.00		14.00					7.00		17.50				7.00					7.00			7.00				
H5421	067	0	1	09	04	H5421_067_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					500.00	33																														33							33					33				33			33			
H5421	068	0	1	09	04	H5421_068_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		40.00		100.00																													40.00		80.00					40.00		100.00				40.00								40.00				
H5421	068	0	1	09	04	H5421_068_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		80.00		200.00																													80.00		160.00					80.00		200.00				80.00								80.00				
H5421	068	0	1	09	04	H5421_068_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					500.00	33																														33							33					33				33			33			
H5421	068	0	1	09	04	H5421_068_0	7	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		7.00		17.50																													7.00		14.00					7.00		17.50				7.00					7.00			7.00				
H5421	068	0	1	09	04	H5421_068_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					2.00		5.00																													2.00		4.00					2.00		5.00				2.00					2.00							
H5421	070	0	1	09	04	H5421_070_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		95.00		237.50																													95.00		190.00					95.00		237.50				95.00								95.00				
H5421	070	0	1	09	04	H5421_070_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					435.00	29																														29							29					29				29			29			
H5421	070	0	1	09	04	H5421_070_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		45.00		112.50																													45.00		90.00					45.00		112.50				45.00								45.00				
H5421	070	0	1	09	04	H5421_070_0	7	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		12.00		30.00																													12.00		24.00					12.00		30.00				12.00					12.00			12.00				
H5421	070	0	1	09	04	H5421_070_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					5.00		12.50																													5.00		10.00					5.00		12.50				5.00					5.00							
H5421	072	0	1	09	04	H5421_072_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					435.00	29																														29							29					29				29			29			
H5421	072	0	1	09	04	H5421_072_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					5.00		12.50																													5.00		10.00					5.00		12.50				5.00					5.00							
H5421	072	0	1	09	04	H5421_072_0	7	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		12.00		30.00																													12.00		24.00					12.00		30.00				12.00					12.00			12.00				
H5421	072	0	1	09	04	H5421_072_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		95.00		237.50																													95.00		190.00					95.00		237.50				95.00								95.00				
H5421	072	0	1	09	04	H5421_072_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		45.00		112.50																													45.00		90.00					45.00		112.50				45.00								45.00				
H5421	073	0	1	09	04	H5421_073_0	7	1	Preferred Generic	1	3	001000		2	010100000010000101101100	30		90							2				30		90	30		90	30		34					5.00		12.50																													5.00		10.00					5.00		12.50				5.00					5.00							
H5421	073	0	1	09	04	H5421_073_0	7	5	Specialty Tier	1	3	010010		1	110000000010000100100101	30													30			30			30		34		34	14					375.00	25																														25							25					25				25			25			
H5421	073	0	1	09	04	H5421_073_0	7	4	Non-Preferred Brand	1	3	100000		2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		90.00		225.00																													90.00		180.00					90.00		225.00				90.00								90.00				
H5421	073	0	1	09	04	H5421_073_0	7	3	Preferred Brand	1	3	000001		2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		45.00		112.50																													45.00		90.00					45.00		112.50				45.00								45.00				
H5421	073	0	1	09	04	H5421_073_0	7	2	Non-Preferred Generic	1	3	000110		2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		12.00		30.00																													12.00		24.00					12.00		30.00				12.00					12.00			12.00				
H5421	074	0	1	09	04	H5421_074_0	7	5	Specialty Tier	1	3	010010		1	110000000010000100100101	30													30			30			30		34		34	14					435.00	29																														29							29					29				29			29			
H5421	074	0	1	09	04	H5421_074_0	7	4	Non-Preferred Brand	1	3	100000		2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		95.00		237.50																													95.00		190.00					95.00		237.50				95.00								95.00				
H5421	074	0	1	09	04	H5421_074_0	7	3	Preferred Brand	1	3	000001		2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		45.00		112.50																													45.00		90.00					45.00		112.50				45.00								45.00				
H5421	074	0	1	09	04	H5421_074_0	7	2	Non-Preferred Generic	1	3	000110		2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		12.00		30.00																													12.00		24.00					12.00		30.00				12.00					12.00			12.00				
H5421	074	0	1	09	04	H5421_074_0	7	1	Preferred Generic	1	3	001000		2	010100000010000101101100	30		90							2				30		90	30		90	30		34					5.00		12.50																													5.00		10.00					5.00		12.50				5.00					5.00							
H5421	075	0	1	09	04	H5421_075_0	7	1	Preferred Generic	1	3	001000		2	010100000010000101101100	30		90							2				30		90	30		90	30		34					5.00		12.50																													5.00		10.00					5.00		12.50				5.00					5.00							
H5421	075	0	1	09	04	H5421_075_0	7	4	Non-Preferred Brand	1	3	100000		2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		75.00		187.50																													75.00		150.00					75.00		187.50				75.00								75.00				
H5421	075	0	1	09	04	H5421_075_0	7	3	Preferred Brand	1	3	000001		2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		45.00		112.50																													45.00		90.00					45.00		112.50				45.00								45.00				
H5421	075	0	1	09	04	H5421_075_0	7	2	Non-Preferred Generic	1	3	000110		2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		10.50		26.25																													10.50		21.00					10.50		26.25				10.50					10.50			10.50				
H5421	075	0	1	09	04	H5421_075_0	7	5	Specialty Tier	1	3	010010		1	110000000010000100100101	30													30			30			30		34		34	14					435.00	29																														29							29					29				29			29			
H5421	212	0	1	09	04	H5421_212_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					500.00	33																														33							33					33				33			33			
H5421	212	0	1	09	04	H5421_212_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		80.00		200.00																													80.00		160.00					80.00		200.00				80.00								80.00				
H5421	212	0	1	09	04	H5421_212_0	7	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		7.00		17.50																													7.00		14.00					7.00		17.50				7.00					7.00			7.00				
H5421	212	0	1	09	04	H5421_212_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					2.00		5.00																													2.00		4.00					2.00		5.00				2.00					2.00							
H5421	212	0	1	09	04	H5421_212_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		40.00		100.00																													40.00		80.00					40.00		100.00				40.00								40.00				
H5421	213	0	1	09	04	H5421_213_0	7	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		7.00		17.50																													7.00		14.00					7.00		17.50				7.00					7.00			7.00				
H5421	213	0	1	09	04	H5421_213_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					500.00	33																														33							33					33				33			33			
H5421	213	0	1	09	04	H5421_213_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					2.00		5.00																													2.00		4.00					2.00		5.00				2.00					2.00							
H5421	213	0	1	09	04	H5421_213_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		40.00		100.00																													40.00		80.00					40.00		100.00				40.00								40.00				
H5421	213	0	1	09	04	H5421_213_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		80.00		200.00																													80.00		160.00					80.00		200.00				80.00								80.00				
H5421	214	0	1	09	04	H5421_214_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		40.00		100.00																													40.00		80.00					40.00		100.00				40.00								40.00				
H5421	214	0	1	09	04	H5421_214_0	7	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		7.00		17.50																													7.00		14.00					7.00		17.50				7.00					7.00			7.00				
H5421	214	0	1	09	04	H5421_214_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		80.00		200.00																													80.00		160.00					80.00		200.00				80.00								80.00				
H5421	214	0	1	09	04	H5421_214_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					500.00	33																														33							33					33				33			33			
H5421	214	0	1	09	04	H5421_214_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					2.00		5.00																													2.00		4.00					2.00		5.00				2.00					2.00							
H5421	215	0	1	09	04	H5421_215_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		40.00		100.00																													40.00		80.00					40.00		100.00				40.00								40.00				
H5421	215	0	1	09	04	H5421_215_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					2.00		5.00																													2.00		4.00					2.00		5.00				2.00					2.00							
H5421	215	0	1	09	04	H5421_215_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		80.00		200.00																													80.00		160.00					80.00		200.00				80.00								80.00				
H5421	215	0	1	09	04	H5421_215_0	7	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		7.00		17.50																													7.00		14.00					7.00		17.50				7.00					7.00			7.00				
H5421	215	0	1	09	04	H5421_215_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					500.00	33																														33							33					33				33			33			
H5422	002	0	1	01	01	H5422_002_0	9	5	Injectable Drugs	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					82.00	33	33	33																					33	33	33																	33				33			33			
H5422	002	0	1	01	01	H5422_002_0	9	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H5422	002	0	1	01	01	H5422_002_0	9	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				10.00	20.00	30.00																						10.00	20.00	15.00																		10.00					10.00							
H5422	002	0	1	01	01	H5422_002_0	9	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				4.00	8.00	12.00																						4.00	8.00	6.00																		4.00					4.00							
H5422	002	0	1	01	01	H5422_002_0	9	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00					45.00			45.00				
H5422	002	0	1	01	01	H5422_002_0	9	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					711.00	33																							33																			33				33			33			
H5422	006	0	1	01	01	H5422_006_0	9	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					429.00	33																							33																			33				33			33			
H5422	006	0	1	01	01	H5422_006_0	9	5	Injectable Drugs	1	4	010010	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H5422	006	0	1	01	01	H5422_006_0	9	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H5422	006	0	1	01	01	H5422_006_0	9	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				10.00	20.00	30.00																						10.00	20.00	15.00																		10.00					10.00							
H5422	006	0	1	01	01	H5422_006_0	9	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				4.00	8.00	12.00																						4.00	8.00	6.00																		4.00					4.00							
H5422	006	0	1	01	01	H5422_006_0	9	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00					45.00			45.00				
H5424	001	0	1	04	01	H5424_001_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H5424	001	0	1	04	01	H5424_001_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H5424	001	0	1	04	01	H5424_001_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					537.00	33		33																														33							33			33				33			33			
H5424	001	0	1	04	01	H5424_001_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H5424	001	0	1	04	01	H5424_001_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H5425	001	0	1	01	01	H5425_001_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010000000000111	31																			31		31	14	31	14					358.85	33																																										33				33			33			
H5425	001	0	1	01	01	H5425_001_0	9	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	31		90							1			90							31				31	14		10.00		30.00																								20.00																		10.00								10.00				
H5425	001	0	1	01	01	H5425_001_0	9	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				7.00		21.00																								14.00																		7.00					7.00					1		
H5425	001	0	1	01	01	H5425_001_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	31		90							1			90							31				31	14		80.00		240.00																								160.00																		80.00								80.00				
H5425	001	0	1	01	01	H5425_001_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	31		90							1			90							31		31	14				10.00		30.00																								20.00																		10.00					10.00							
H5425	001	0	1	01	01	H5425_001_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	31		90							1			90							31				31	14		40.00		120.00																								80.00																		40.00								40.00				
H5425	001	0	1	01	01	H5425_001_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				7.00		21.00																								14.00																		7.00					7.00							
H5425	003	0	1	01	01	H5425_003_0	9	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	31		90							1			90							31				31	14		10.00		30.00																								20.00																		10.00								10.00				
H5425	003	0	1	01	01	H5425_003_0	9	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				7.00		21.00																								14.00																		7.00					7.00					1		
H5425	003	0	1	01	01	H5425_003_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				7.00		21.00																								14.00																		7.00					7.00							
H5425	003	0	1	01	01	H5425_003_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	31		90							1			90							31		31	14				10.00		30.00																								20.00																		10.00					10.00							
H5425	003	0	1	01	01	H5425_003_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	31		90							1			90							31				31	14		40.00		120.00																								80.00																		40.00								40.00				
H5425	003	0	1	01	01	H5425_003_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	31		90							1			90							31				31	14		75.00		225.00																								150.00																		75.00								75.00				
H5425	003	0	1	01	01	H5425_003_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010000000000111	31																			31		31	14	31	14					378.87	33																																										33				33			33			
H5425	004	0	1	01	01	H5425_004_0	9	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	31		90							1			90							31		31	14				8.00		24.00																								16.00																		8.00					8.00					1		
H5425	004	0	1	01	01	H5425_004_0	9	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				3.00		9.00																								6.00																		3.00					3.00					1		
H5425	004	0	1	01	01	H5425_004_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				3.00		9.00																								6.00																		3.00					3.00							
H5425	004	0	1	01	01	H5425_004_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	31		90							1			90							31		31	14				8.00		24.00																								16.00																		8.00					8.00							
H5425	004	0	1	01	01	H5425_004_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	31		90							1			90							31				31	14		34.00		102.00																								68.00																		34.00								34.00				
H5425	004	0	1	01	01	H5425_004_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	31		90							1			90							31				31	14		70.00		210.00																								140.00																		70.00								70.00				
H5425	004	0	1	01	01	H5425_004_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010000000000111	31																			31		31	14	31	14					373.44	33																																										33				33			33			
H5425	004	0	1	01	01	H5425_004_0	9	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	31		90							1			90							31				31	14		10.00		30.00																								20.00																		10.00								10.00				
H5425	005	0	1	01	01	H5425_005_0	8	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	31		90							1			90							31		31	14				8.00		24.00																								16.00																		8.00					8.00					1		
H5425	005	0	1	01	01	H5425_005_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	31		90							1			90							31		31	14				8.00		24.00																								16.00																		8.00					8.00							
H5425	005	0	1	01	01	H5425_005_0	8	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	31		90							1			90							31				31	14		40.00		120.00																								80.00																		40.00								40.00				
H5425	005	0	1	01	01	H5425_005_0	8	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	31		90							1			90							31				31	14		75.00		225.00																								150.00																		75.00								75.00				
H5425	005	0	1	01	01	H5425_005_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010000000000111	31																			31		31	14	31	14					383.70	33																																										33				33			33			
H5425	005	0	1	01	01	H5425_005_0	8	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	31		90							1			90							31				31	14		10.00		30.00																								20.00																		10.00								10.00				
H5425	005	0	1	01	01	H5425_005_0	8	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				3.00		9.00																								6.00																		3.00					3.00					1		
H5425	005	0	1	01	01	H5425_005_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				3.00		9.00																								6.00																		3.00					3.00							
H5425	006	0	1	01	01	H5425_006_0	11	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				3.00		9.00																								6.00																		3.00					3.00					1		
H5425	006	0	1	01	01	H5425_006_0	11	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	31		90							1			90							31		31	14				8.00		24.00																								16.00																		8.00					8.00					1		
H5425	006	0	1	01	01	H5425_006_0	11	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	31		90							1			90							31				31	14		10.00		30.00																								20.00																		10.00								10.00				
H5425	006	0	1	01	01	H5425_006_0	11	5	Specialty Tier	1	4	010010	1	1	110000000010000000000111	31																			31		31	14	31	14					416.51	33																																										33				33			33			
H5425	006	0	1	01	01	H5425_006_0	11	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	31		90							1			90							31				31	14		80.00		240.00																								160.00																		80.00								80.00				
H5425	006	0	1	01	01	H5425_006_0	11	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	31		90							1			90							31				31	14		40.00		120.00																								80.00																		40.00								40.00				
H5425	006	0	1	01	01	H5425_006_0	11	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	31		90							1			90							31		31	14				8.00		24.00																								16.00																		8.00					8.00							
H5425	006	0	1	01	01	H5425_006_0	11	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				3.00		9.00																								6.00																		3.00					3.00							
H5425	007	0	1	01	01	H5425_007_0	9	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	31		90							1			90							31		31	14				10.00		30.00																								20.00																		10.00					10.00					1		
H5425	007	0	1	01	01	H5425_007_0	9	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				4.00		12.00																								8.00																		4.00					4.00					1		
H5425	007	0	1	01	01	H5425_007_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				4.00		12.00																								8.00																		4.00					4.00							
H5425	007	0	1	01	01	H5425_007_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	31		90							1			90							31		31	14				10.00		30.00																								20.00																		10.00					10.00							
H5425	007	0	1	01	01	H5425_007_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	31		90							1			90							31				31	14		40.00		120.00																								80.00																		40.00								40.00				
H5425	007	0	1	01	01	H5425_007_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	31		90							1			90							31				31	14		75.00		225.00																								150.00																		75.00								75.00				
H5425	007	0	1	01	01	H5425_007_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010000000000111	31																			31		31	14	31	14					418.84	33																																										33				33			33			
H5425	007	0	1	01	01	H5425_007_0	9	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	31		90							1			90							31				31	14		10.00		30.00																								20.00																		10.00								10.00				
H5425	008	0	1	01	01	H5425_008_0	10	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	31		90							1			90							31		31	14				8.00		24.00																								16.00																		8.00					8.00					1		
H5425	008	0	1	01	01	H5425_008_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	31		90							1			90							31		31	14				8.00		24.00																								16.00																		8.00					8.00							
H5425	008	0	1	01	01	H5425_008_0	10	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	31		90							1			90							31				31	14		40.00		120.00																								80.00																		40.00								40.00				
H5425	008	0	1	01	01	H5425_008_0	10	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	31		90							1			90							31				31	14		75.00		225.00																								150.00																		75.00								75.00				
H5425	008	0	1	01	01	H5425_008_0	10	5	Specialty Tier	1	4	010010	1	1	110000000010000000000111	31																			31		31	14	31	14					396.28	33																																										33				33			33			
H5425	008	0	1	01	01	H5425_008_0	10	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	31		90							1			90							31				31	14		10.00		30.00																								20.00																		10.00								10.00				
H5425	008	0	1	01	01	H5425_008_0	10	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				3.00		9.00																								6.00																		3.00					3.00					1		
H5425	008	0	1	01	01	H5425_008_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				3.00		9.00																								6.00																		3.00					3.00							
H5425	009	0	1	01	01	H5425_009_0	9	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	31		90							1			90							31				31	14		10.00		30.00																								20.00																		10.00								10.00				
H5425	009	0	1	01	01	H5425_009_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010000000000111	31																			31		31	14	31	14					354.28	33																																										33				33			33			
H5425	009	0	1	01	01	H5425_009_0	9	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				3.00		9.00																								6.00																		3.00					3.00					1		
H5425	009	0	1	01	01	H5425_009_0	9	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	31		90							1			90							31		31	14				8.00		24.00																								16.00																		8.00					8.00					1		
H5425	009	0	1	01	01	H5425_009_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	31		90							1			90							31				31	14		75.00		225.00																								150.00																		75.00								75.00				
H5425	009	0	1	01	01	H5425_009_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	31		90							1			90							31				31	14		40.00		120.00																								80.00																		40.00								40.00				
H5425	009	0	1	01	01	H5425_009_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	31		90							1			90							31		31	14				8.00		24.00																								16.00																		8.00					8.00							
H5425	009	0	1	01	01	H5425_009_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				3.00		9.00																								6.00																		3.00					3.00							
H5425	018	0	1	01	01	H5425_018_0	8	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	31		90							1			90							31				31	14		65.00		195.00																								130.00																		65.00								65.00				
H5425	018	0	1	01	01	H5425_018_0	8	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	31		90							1			90							31				31	14		40.00		120.00																								80.00																		40.00								40.00				
H5425	018	0	1	01	01	H5425_018_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	31		90							1			90							31		31	14				10.00		30.00																								20.00																		10.00					10.00							
H5425	018	0	1	01	01	H5425_018_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				5.00		15.00																								10.00																		5.00					5.00							
H5425	018	0	1	01	01	H5425_018_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010000000000111	31																			31		31	14	31	14					389.42	33																																										33				33			33			
H5425	018	0	1	01	01	H5425_018_0	8	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	31		90							1			90							31				31	14		10.00		30.00																								20.00																		10.00								10.00				
H5425	018	0	1	01	01	H5425_018_0	8	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				5.00		15.00																								10.00																		5.00					5.00					1		
H5425	018	0	1	01	01	H5425_018_0	8	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	31		90							1			90							31		31	14				10.00		30.00																								20.00																		10.00					10.00					1		
H5425	019	0	1	01	01	H5425_019_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				5.00		15.00																								10.00																		5.00					5.00							
H5425	019	0	1	01	01	H5425_019_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	31		90							1			90							31		31	14				10.00		30.00																								20.00																		10.00					10.00							
H5425	019	0	1	01	01	H5425_019_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	31		90							1			90							31				31	14		45.00		135.00																								90.00																		45.00								45.00				
H5425	019	0	1	01	01	H5425_019_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	31		90							1			90							31				31	14		75.00		225.00																								150.00																		75.00								75.00				
H5425	019	0	1	01	01	H5425_019_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010000000000111	31																			31		31	14	31	14					220.41	33																																										33				33			33			
H5425	019	0	1	01	01	H5425_019_0	9	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	31		90							1			90							31				31	14		10.00		30.00																								20.00																		10.00								10.00				
H5425	020	0	1	01	01	H5425_020_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	31		90							1			90							31		31	14				10.00		30.00																								20.00																		10.00					10.00							
H5425	020	0	1	01	01	H5425_020_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	31		90							1			90							31				31	14		45.00		135.00																								90.00																		45.00								45.00				
H5425	020	0	1	01	01	H5425_020_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	31		90							1			90							31				31	14		75.00		225.00																								150.00																		75.00								75.00				
H5425	020	0	1	01	01	H5425_020_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010000000000111	31																			31		31	14	31	14					459.99	33																																										33				33			33			
H5425	020	0	1	01	01	H5425_020_0	9	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	31		90							1			90							31				31	14		10.00		30.00																								20.00																		10.00								10.00				
H5425	020	0	1	01	01	H5425_020_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				5.00		15.00																								10.00																		5.00					5.00							
H5425	022	0	1	01	01	H5425_022_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010000000000111	31																			31		31	14	31	14					329.91	33																																										33				33			33			
H5425	022	0	1	01	01	H5425_022_0	9	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	31		90							1			90							31				31	14		10.00		30.00																								20.00																		10.00								10.00				
H5425	022	0	1	01	01	H5425_022_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	31		90							1			90							31				31	14		75.00		225.00																								150.00																		75.00								75.00				
H5425	022	0	1	01	01	H5425_022_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	31		90							1			90							31		31	14				10.00		30.00																								20.00																		10.00					10.00							
H5425	022	0	1	01	01	H5425_022_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				5.00		15.00																								10.00																		5.00					5.00							
H5425	022	0	1	01	01	H5425_022_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	31		90							1			90							31				31	14		45.00		135.00																								90.00																		45.00								45.00				
H5425	028	0	1	01	01	H5425_028_0	11	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	31		90							1			90							31				31	14		30.00		90.00																								60.00																		30.00								30.00				
H5425	028	0	1	01	01	H5425_028_0	11	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	31		90							1			90							31		31	14				5.00		15.00																								10.00																		5.00					5.00					1		
H5425	028	0	1	01	01	H5425_028_0	11	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H5425	028	0	1	01	01	H5425_028_0	11	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	31		90							1			90							31				31	14		0.00		0.00																								0.00																		0.00								0.00				
H5425	028	0	1	01	01	H5425_028_0	11	5	Specialty Tier	1	4	010010	1	1	110000000010000000000111	31																			31		31	14	31	14					176.89	33																																										33				33			33			
H5425	028	0	1	01	01	H5425_028_0	11	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	31		90							1			90							31				31	14		70.00		210.00																								140.00																		70.00								70.00				
H5425	028	0	1	01	01	H5425_028_0	11	6	Select Care Drugs	3	4	000010	1	2	110100000010001000000001	31		90							1			90							31				31	14		0.00		0.00																								0.00																		0.00								0.00		1		
H5425	028	0	1	01	01	H5425_028_0	11	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	31		90							1			90							31		31	14				5.00		15.00																								10.00																		5.00					5.00							
H5425	028	0	1	01	01	H5425_028_0	11	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5425	033	0	1	01	01	H5425_033_0	10	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	31		90							1			90							31				31	14		0.00		0.00																								0.00																		0.00								0.00				
H5425	033	0	1	01	01	H5425_033_0	10	5	Specialty Tier	1	4	010010	1	1	110000000010000000000111	31																			31		31	14	31	14					176.89	33																																										33				33			33			
H5425	033	0	1	01	01	H5425_033_0	10	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	31		90							1			90							31				31	14		70.00		210.00																								140.00																		70.00								70.00				
H5425	033	0	1	01	01	H5425_033_0	10	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	31		90							1			90							31				31	14		30.00		90.00																								60.00																		30.00								30.00				
H5425	033	0	1	01	01	H5425_033_0	10	6	Select Care Drugs	3	4	000010	1	2	110100000010001000000001	31		90							1			90							31				31	14		0.00		0.00																								0.00																		0.00								0.00		1		
H5425	033	0	1	01	01	H5425_033_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5425	033	0	1	01	01	H5425_033_0	10	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H5425	033	0	1	01	01	H5425_033_0	10	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	31		90							1			90							31		31	14				5.00		15.00																								10.00																		5.00					5.00					1		
H5425	033	0	1	01	01	H5425_033_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	31		90							1			90							31		31	14				5.00		15.00																								10.00																		5.00					5.00							
H5425	034	0	1	01	01	H5425_034_0	12	6	Select Care Drugs	3	4	000010	1	2	110100000010001000000001	31		90							1			90							31				31	14		0.00		0.00																								0.00																		0.00								0.00		1		
H5425	034	0	1	01	01	H5425_034_0	12	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5425	034	0	1	01	01	H5425_034_0	12	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	31		90							1			90							31		31	14				5.00		15.00																								10.00																		5.00					5.00							
H5425	034	0	1	01	01	H5425_034_0	12	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	31		90							1			90							31				31	14		30.00		90.00																								60.00																		30.00								30.00				
H5425	034	0	1	01	01	H5425_034_0	12	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	31		90							1			90							31				31	14		70.00		210.00																								140.00																		70.00								70.00				
H5425	034	0	1	01	01	H5425_034_0	12	5	Specialty Tier	1	4	010010	1	1	110000000010000000000111	31																			31		31	14	31	14					184.37	33																																										33				33			33			
H5425	034	0	1	01	01	H5425_034_0	12	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	31		90							1			90							31				31	14		0.00		0.00																								0.00																		0.00								0.00				
H5425	034	0	1	01	01	H5425_034_0	12	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H5425	034	0	1	01	01	H5425_034_0	12	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	31		90							1			90							31		31	14				5.00		15.00																								10.00																		5.00					5.00					1		
H5425	035	0	1	01	01	H5425_035_0	10	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	31		90							1			90							31		31	14				5.00		15.00																								10.00																		5.00					5.00					1		
H5425	035	0	1	01	01	H5425_035_0	10	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H5425	035	0	1	01	01	H5425_035_0	10	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	31		90							1			90							31				31	14		0.00		0.00																								0.00																		0.00								0.00				
H5425	035	0	1	01	01	H5425_035_0	10	5	Specialty Tier	1	4	010010	1	1	110000000010000000000111	31																			31		31	14	31	14					184.37	33																																										33				33			33			
H5425	035	0	1	01	01	H5425_035_0	10	6	Select Care Drugs	3	4	000010	1	2	110100000010001000000001	31		90							1			90							31				31	14		0.00		0.00																								0.00																		0.00								0.00		1		
H5425	035	0	1	01	01	H5425_035_0	10	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	31		90							1			90							31				31	14		30.00		90.00																								60.00																		30.00								30.00				
H5425	035	0	1	01	01	H5425_035_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	31		90							1			90							31		31	14				5.00		15.00																								10.00																		5.00					5.00							
H5425	035	0	1	01	01	H5425_035_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5425	035	0	1	01	01	H5425_035_0	10	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	31		90							1			90							31				31	14		70.00		210.00																								140.00																		70.00								70.00				
H5425	037	0	1	01	01	H5425_037_0	9	4	Non-Preferred Brand	1	4	100000	1	1	110100000010001000000001	31		90							1			90							31				31	14					90.41	25		25																							25																	25							25			
H5425	037	0	1	01	01	H5425_037_0	9	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	31		90							1			90							31				31	14		10.00		30.00																								20.00																		10.00								10.00				
H5425	037	0	1	01	01	H5425_037_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010000000000111	31																			31		31	14	31	14					394.23	25																																										25				25			25			
H5425	037	0	1	01	01	H5425_037_0	9	3	Preferred Brand	1	4	000001	1	1	110100000010001000000001	31		90							1			90							31				31	14					36.17	25		25																							25																	25							25			
H5425	037	0	1	01	01	H5425_037_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	31		90							1			90							31		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5425	037	0	1	01	01	H5425_037_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5425	040	0	1	01	01	H5425_040_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010000000000111	31																			31		31	14	31	14					394.23	25																																										25				25			25			
H5425	040	0	1	01	01	H5425_040_0	9	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	31		90							1			90							31				31	14		10.00		30.00																								20.00																		10.00								10.00				
H5425	040	0	1	01	01	H5425_040_0	9	4	Non-Preferred Brand	1	4	100000	1	1	110100000010001000000001	31		90							1			90							31				31	14					90.41	25		25																							25																	25							25			
H5425	040	0	1	01	01	H5425_040_0	9	3	Preferred Brand	1	4	000001	1	1	110100000010001000000001	31		90							1			90							31				31	14					36.17	25		25																							25																	25							25			
H5425	040	0	1	01	01	H5425_040_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	31		90							1			90							31		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5425	040	0	1	01	01	H5425_040_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5425	041	0	1	01	01	H5425_041_0	9	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	31		90							1			90							31				31	14		10.00		30.00																								20.00																		10.00								10.00				
H5425	041	0	1	01	01	H5425_041_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5425	041	0	1	01	01	H5425_041_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	31		90							1			90							31		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5425	041	0	1	01	01	H5425_041_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010000000000111	31																			31		31	14	31	14					394.23	25																																										25				25			25			
H5425	041	0	1	01	01	H5425_041_0	9	3	Preferred Brand	1	4	000001	1	1	110100000010001000000001	31		90							1			90							31				31	14					36.17	25		25																							25																	25							25			
H5425	041	0	1	01	01	H5425_041_0	9	4	Non-Preferred Brand	1	4	100000	1	1	110100000010001000000001	31		90							1			90							31				31	14					90.41	25		25																							25																	25							25			
H5426	001	0	1	01	01	H5426_001_0	3	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H5426	001	0	1	01	01	H5426_001_0	3	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					980.00	33																														33							33					33				33			33	2	3	
H5426	001	0	1	01	01	H5426_001_0	3	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00		2	3	
H5426	001	0	1	01	01	H5426_001_0	3	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H5426	001	0	1	01	01	H5426_001_0	3	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00		2	2	
H5426	001	0	1	01	01	H5426_001_0	3	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	1
H5426	001	0	1	01	01	H5426_001_0	3	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					791.00	33																														33							33					33				33			33			
H5426	001	0	1	01	01	H5426_001_0	3	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00				
H5426	001	0	1	01	01	H5426_001_0	3	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H5426	001	0	1	01	01	H5426_001_0	3	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H5426	002	0	1	01	01	H5426_002_0	4	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H5426	002	0	1	01	01	H5426_002_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H5426	002	0	1	01	01	H5426_002_0	4	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		44.00		132.00																													44.00		122.00					44.00		132.00				44.00					44.00			44.00		2	2	
H5426	002	0	1	01	01	H5426_002_0	4	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H5426	002	0	1	01	01	H5426_002_0	4	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1097.00	33																														33							33					33				33			33	2	3	
H5426	002	0	1	01	01	H5426_002_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					967.00	33																														33							33					33				33			33			
H5426	002	0	1	01	01	H5426_002_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H5426	002	0	1	01	01	H5426_002_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		44.00		132.00																													44.00		122.00					44.00		132.00				44.00					44.00			44.00				
H5426	002	0	1	01	01	H5426_002_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H5426	002	0	1	01	01	H5426_002_0	4	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H5426	008	0	1	01	01	H5426_008_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					607.00	33																														33							33					33				33			33	2	3	
H5426	008	0	1	01	01	H5426_008_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		86.00		258.00																													86.00		248.00					86.00		258.00				86.00					86.00			86.00		2	3	
H5426	008	0	1	01	01	H5426_008_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		43.00		129.00																													43.00		119.00					43.00		129.00				43.00					43.00			43.00		2	2	
H5426	008	0	1	01	01	H5426_008_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00		2	2	
H5426	008	0	1	01	01	H5426_008_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00		2	3	1
H5426	008	0	1	01	01	H5426_008_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					529.00	33																														33							33					33				33			33			
H5426	008	0	1	01	01	H5426_008_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		86.00		258.00																													86.00		248.00					86.00		258.00				86.00					86.00			86.00				
H5426	008	0	1	01	01	H5426_008_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		43.00		129.00																													43.00		119.00					43.00		129.00				43.00					43.00			43.00				
H5426	008	0	1	01	01	H5426_008_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00				
H5426	008	0	1	01	01	H5426_008_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00				
H5426	013	0	1	01	01	H5426_013_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		38.00		114.00																													38.00		104.00					38.00		114.00				38.00					38.00			38.00				
H5426	013	0	1	01	01	H5426_013_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		82.00		246.00																													82.00		236.00					82.00		246.00				82.00					82.00			82.00				
H5426	013	0	1	01	01	H5426_013_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					514.00	25																														25							25					25				25			25			
H5426	013	0	1	01	01	H5426_013_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		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	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H5426	019	0	1	01	01	H5426_019_0	8	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H5426	019	0	1	01	01	H5426_019_0	8	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H5426	019	0	1	01	01	H5426_019_0	8	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1379.00	33																														33							33					33				33			33	2	3	
H5426	019	0	1	01	01	H5426_019_0	8	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		79.00		237.00																													79.00		227.00					79.00		237.00				79.00					79.00			79.00		2	3	
H5426	019	0	1	01	01	H5426_019_0	8	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		36.00		108.00																													36.00		98.00					36.00		108.00				36.00					36.00			36.00		2	2	
H5426	019	0	1	01	01	H5426_019_0	8	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H5426	019	0	1	01	01	H5426_019_0	8	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		36.00		108.00																													36.00		98.00					36.00		108.00				36.00					36.00			36.00				
H5426	019	0	1	01	01	H5426_019_0	8	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		79.00		237.00																													79.00		227.00					79.00		237.00				79.00					79.00			79.00				
H5426	019	0	1	01	01	H5426_019_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1119.00	33																														33							33					33				33			33			
H5426	019	0	1	01	01	H5426_019_0	8	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	1
H5426	025	0	1	01	01	H5426_025_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		94.00		282.00																													94.00		272.00					94.00		282.00				94.00					94.00			94.00				
H5426	025	0	1	01	01	H5426_025_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H5426	025	0	1	01	01	H5426_025_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H5426	025	0	1	01	01	H5426_025_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H5426	025	0	1	01	01	H5426_025_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					489.00	25																														25							25					25				25			25			
H5427	053	0	1	01	01	H5427_053_0	7	1	Preferred Generic	1	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00				
H5427	053	0	1	01	01	H5427_053_0	7	2	Preferred Brand	1	4	000101	1	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		25.00		75.00																						25.00		50.00																		25.00					25.00			25.00				
H5427	053	0	1	01	01	H5427_053_0	7	3	Non-Preferred Brand	1	4	100100	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		65.00		195.00																						65.00		130.00																		65.00					65.00			65.00				
H5427	053	0	1	01	01	H5427_053_0	7	4	Specialty Tier	1	4	100100	1	1	110100000010101000000111	30		90							1	30		90							30		31	14	31	14					789.00	33		33																					33		33																	33				33			33			
H5427	054	0	1	01	01	H5427_054_0	7	1	Preferred Generic	1	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00				
H5427	054	0	1	01	01	H5427_054_0	7	2	Preferred Brand	1	4	000101	1	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		25.00		75.00																						25.00		50.00																		25.00					25.00			25.00				
H5427	054	0	1	01	01	H5427_054_0	7	3	Non-Preferred Brand	1	4	100100	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		65.00		195.00																						65.00		130.00																		65.00					65.00			65.00				
H5427	054	0	1	01	01	H5427_054_0	7	4	Specialty Tier	1	4	100100	1	1	110100000010101000000111	30		90							1	30		90							30		31	14	31	14					700.00	33		33																					33		33																	33				33			33			
H5427	059	0	1	01	01	H5427_059_0	7	3	Non-Preferred Brand	1	4	100100	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		60.00		180.00																						60.00		120.00																		60.00					60.00			60.00				
H5427	059	0	1	01	01	H5427_059_0	7	4	Specialty Tier	1	4	100100	1	1	110100000010101000000111	30		90							1	30		90							30		31	14	31	14					496.00	33		33																					33		33																	33				33			33			
H5427	059	0	1	01	01	H5427_059_0	7	2	Preferred Brand	1	4	000101	1	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		20.00		60.00																						20.00		40.00																		20.00					20.00			20.00				
H5427	059	0	1	01	01	H5427_059_0	7	1	Preferred Generic	3	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		5.00		15.00																						5.00		10.00																		5.00					5.00			5.00		1		
H5427	059	0	1	01	01	H5427_059_0	7	1	Preferred Generic	1	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00				
H5427	060	0	1	01	01	H5427_060_0	6	2	Preferred Brand	1	4	000101	1	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		20.00		60.00																						20.00		40.00																		20.00					20.00			20.00				
H5427	060	0	1	01	01	H5427_060_0	6	4	Specialty Tier	1	4	100100	1	1	110100000010101000000111	30		90							1	30		90							30		31	14	31	14					573.00	33		33																					33		33																	33				33			33			
H5427	060	0	1	01	01	H5427_060_0	6	1	Preferred Generic	1	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00				
H5427	060	0	1	01	01	H5427_060_0	6	3	Non-Preferred Brand	1	4	100100	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		60.00		180.00																						60.00		120.00																		60.00					60.00			60.00				
H5427	060	0	1	01	01	H5427_060_0	6	1	Preferred Generic	3	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00		1		
H5427	070	0	1	01	01	H5427_070_0	7	1	Preferred Generic	3	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00		1		
H5427	070	0	1	01	01	H5427_070_0	7	3	Non-Preferred Brand	1	4	100100	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		60.00		180.00																						60.00		120.00																		60.00					60.00			60.00				
H5427	070	0	1	01	01	H5427_070_0	7	4	Specialty Tier	1	4	100100	1	1	110100000010101000000111	30		90							1	30		90							30		31	14	31	14					600.00	33		33																					33		33																	33				33			33			
H5427	070	0	1	01	01	H5427_070_0	7	2	Preferred Brand	1	4	000101	1	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		5.00		15.00																						5.00		10.00																		5.00					5.00			5.00				
H5427	070	0	1	01	01	H5427_070_0	7	1	Preferred Generic	1	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00				
H5427	072	0	1	01	01	H5427_072_0	8	2	Preferred Brand	1	4	000101	1	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		20.00		60.00																						20.00		40.00																		20.00					20.00			20.00				
H5427	072	0	1	01	01	H5427_072_0	8	1	Preferred Generic	1	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00				
H5427	072	0	1	01	01	H5427_072_0	8	3	Non-Preferred Brand	1	4	100100	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		60.00		180.00																						60.00		120.00																		60.00					60.00			60.00				
H5427	072	0	1	01	01	H5427_072_0	8	4	Specialty Tier	1	4	100100	1	1	110100000010101000000111	30		90							1	30		90							30		31	14	31	14					652.00	33		33																					33		33																	33				33			33			
H5427	076	0	1	01	01	H5427_076_0	7	1	Preferred Generic	3	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00		1		
H5427	076	0	1	01	01	H5427_076_0	7	2	Preferred Brand	1	4	000101	1	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		5.00		15.00																						5.00		10.00																		5.00					5.00			5.00				
H5427	076	0	1	01	01	H5427_076_0	7	1	Preferred Generic	1	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00				
H5427	076	0	1	01	01	H5427_076_0	7	4	Specialty Tier	1	4	100100	1	1	110100000010101000000111	30		90							1	30		90							30		31	14	31	14					777.00	33		33																					33		33																	33				33			33			
H5427	076	0	1	01	01	H5427_076_0	7	3	Non-Preferred Brand	1	4	100100	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		60.00		180.00																						60.00		120.00																		60.00					60.00			60.00				
H5427	077	0	1	01	01	H5427_077_0	8	2	Preferred Brand	1	4	000101	1	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		20.00		60.00																						20.00		40.00																		20.00					20.00			20.00				
H5427	077	0	1	01	01	H5427_077_0	8	3	Non-Preferred Brand	1	4	100100	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		60.00		180.00																						60.00		120.00																		60.00					60.00			60.00				
H5427	077	0	1	01	01	H5427_077_0	8	4	Specialty Tier	1	4	100100	1	1	110100000010101000000111	30		90							1	30		90							30		31	14	31	14					659.00	33		33																					33		33																	33				33			33			
H5427	077	0	1	01	01	H5427_077_0	8	1	Preferred Generic	1	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00				
H5427	082	0	1	01	01	H5427_082_0	8	4	Specialty Tier	1	4	100100	1	1	110100000010101000000111	30		90							1	30		90							30		31	14	31	14					810.00	33		33																					33		33																	33				33			33			
H5427	082	0	1	01	01	H5427_082_0	8	3	Non-Preferred Brand	1	4	100100	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		60.00		180.00																						60.00		120.00																		60.00					60.00			60.00				
H5427	082	0	1	01	01	H5427_082_0	8	1	Preferred Generic	1	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00				
H5427	082	0	1	01	01	H5427_082_0	8	2	Preferred Brand	1	4	000101	1	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		20.00		60.00																						20.00		40.00																		20.00					20.00			20.00				
H5427	083	0	1	01	01	H5427_083_0	8	4	Specialty Tier	1	4	100100	1	1	110100000010101000000111	30		90							1	30		90							30		31	14	31	14					1296.00	33		33																					33		33																	33				33			33			
H5427	083	0	1	01	01	H5427_083_0	8	1	Preferred Generic	1	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00				
H5427	083	0	1	01	01	H5427_083_0	8	2	Preferred Brand	1	4	000101	1	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		20.00		60.00																						20.00		40.00																		20.00					20.00			20.00				
H5427	083	0	1	01	01	H5427_083_0	8	3	Non-Preferred Brand	1	4	100100	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		60.00		180.00																						60.00		120.00																		60.00					60.00			60.00				
H5427	084	0	1	01	01	H5427_084_0	7	3	Non-Preferred Brand	1	4	100100	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		65.00		195.00																						65.00		130.00																		65.00					65.00			65.00				
H5427	084	0	1	01	01	H5427_084_0	7	2	Preferred Brand	1	4	000101	1	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		25.00		75.00																						25.00		50.00																		25.00					25.00			25.00				
H5427	084	0	1	01	01	H5427_084_0	7	1	Preferred Generic	1	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00				
H5427	084	0	1	01	01	H5427_084_0	7	4	Specialty Tier	1	4	100100	1	1	110100000010101000000111	30		90							1	30		90							30		31	14	31	14					663.00	33		33																					33		33																	33				33			33			
H5428	001	0	1	01	01	H5428_001_0	5	2	Brand	1	4	000010	1	2	110100000010000000000001	31		93							2										31				31	7		45.00		135.00																																										45.00								45.00				
H5428	001	0	1	01	01	H5428_001_0	5	1	Generic	1	4	010000	1	2	010100000010000000000110	31		93							2										31		31	7				0.00		0.00																																										0.00					0.00							
H5431	001	0	1	01	01	H5431_001_0	5	5	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													200.00	25							200.00	33																										33				33			33			
H5431	001	0	1	01	01	H5431_001_0	5	6	Supplemental Brand and Generic Drugs	1	4	010010	2	2	100010010010000000000101				30			30													30		31		31	14										0.00								10.00																												10.00					10.00			10.00				
H5431	001	0	1	01	01	H5431_001_0	5	1	Preferred Generic	1	4	001000	1	2	000010010010000000000100				30			30													30		31													0.00								0.00																												0.00					0.00							
H5431	001	0	1	01	01	H5431_001_0	5	2	Non-Preferred Generic	1	4	000100	1	2	000010010010000000000100				30			30													30		31													0.00								10.00																												10.00					10.00							
H5431	001	0	1	01	01	H5431_001_0	5	3	Preferred Brand	1	4	000001	1	2	100010010010000000000001				30			30													30				31	14										0.00								10.00																												10.00								10.00				
H5431	001	0	1	01	01	H5431_001_0	5	4	Non-Preferred Brand	1	4	100000	1	2	100010010010000000000001				30			30													30				31	14										10.00								50.00																												50.00								50.00				
H5431	002	0	1	01	01	H5431_002_0	4	1	Preferred Generic	1	4	001000	1	2	000010010010000000000100				30			30													30		31													0.00								0.00																												0.00					0.00							
H5431	002	0	1	01	01	H5431_002_0	4	3	Preferred Brand	1	4	000001	1	2	100010010010000000000001				30			30													30				31	14										0.00								10.00																												10.00								10.00				
H5431	002	0	1	01	01	H5431_002_0	4	4	Non-Preferred Brand	1	4	100000	1	2	100010010010000000000001				30			30													30				31	14										15.00								50.00																												50.00								50.00				
H5431	002	0	1	01	01	H5431_002_0	4	5	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													200.00	25							200.00	33																										33				33			33			
H5431	002	0	1	01	01	H5431_002_0	4	2	Non-Preferred Generic	1	4	000100	1	2	000010010010000000000100				30			30													30		31													0.00								10.00																												10.00					10.00							
H5431	002	0	1	01	01	H5431_002_0	4	6	Supplemental Brand and Generic Drugs	1	4	010010	2	2	100010010010000000000101				30			30													30		31		31	14										0.00								10.00																												10.00					10.00			10.00				
H5431	005	0	1	01	01	H5431_005_0	5	6	Supplemental Brand and Generic Drugs	1	4	010010	2	2	100010010010000000000101				30			30													30		31		31	14										0.00								10.00																												10.00					10.00			10.00				
H5431	005	0	1	01	01	H5431_005_0	5	6	Supplemental Brand and Generic Drugs	3	4	010010	2	2	100010010010000000000101				30			30													30		31		31	14										0.00								10.00																												10.00					10.00			10.00		1		
H5431	005	0	1	01	01	H5431_005_0	5	2	Non-Preferred Generic	3	4	000100	1	2	000010010010000000000100				30			30													30		31													0.00								10.00																												10.00					10.00					1		
H5431	005	0	1	01	01	H5431_005_0	5	1	Preferred Generic	3	4	001000	1	2	000010010010000000000100				30			30													30		31													0.00								0.00																												0.00					0.00					1		
H5431	005	0	1	01	01	H5431_005_0	5	5	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													200.00	33							200.00	33																										33				33			33			
H5431	005	0	1	01	01	H5431_005_0	5	4	Non-Preferred Brand	1	4	100000	1	1	100010010010000000000001				30			30													30				31	14													50.00	33							50.00	33																										33							33			
H5431	005	0	1	01	01	H5431_005_0	5	3	Preferred Brand	1	4	000001	1	1	100010010010000000000001				30			30													30				31	14													10.00	25							10.00	25																										25							25			
H5431	005	0	1	01	01	H5431_005_0	5	2	Non-Preferred Generic	1	4	000100	1	2	000010010010000000000100				30			30													30		31													0.00								10.00																												10.00					10.00							
H5431	005	0	1	01	01	H5431_005_0	5	1	Preferred Generic	1	4	001000	1	2	000010010010000000000100				30			30													30		31													0.00								0.00																												0.00					0.00							
H5431	006	0	1	01	01	H5431_006_0	5	1	Preferred Generic	1	4	001000	1	1	000010010010000000000100				30			30													30		31																10.00	25							10.00	25																										25				25						
H5431	006	0	1	01	01	H5431_006_0	5	4	Non-Preferred Brand	1	4	100000	1	1	100010010010000000000001				30			30													30				31	14													50.00	25							50.00	25																										25							25			
H5431	006	0	1	01	01	H5431_006_0	5	2	Non-Preferred Generic	1	4	000100	1	1	000010010010000000000100				30			30													30		31																10.00	25							10.00	25																										25				25						
H5431	006	0	1	01	01	H5431_006_0	5	3	Preferred Brand	1	4	000001	1	1	100010010010000000000001				30			30													30				31	14													35.00	25							35.00	25																										25							25			
H5431	006	0	1	01	01	H5431_006_0	5	6	Supplemental Brand and Generic Drugs	3	4	010010	2	2	100010010010000000000101				30			30													30		31		31	14										0.00								10.00																												10.00					10.00			10.00		1		
H5431	006	0	1	01	01	H5431_006_0	5	6	Supplemental Brand and Generic Drugs	1	4	010010	2	2	100010010010000000000101				30			30													30		31		31	14										0.00								10.00																												10.00					10.00			10.00				
H5431	006	0	1	01	01	H5431_006_0	5	5	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													200.00	25							200.00	25																										25				25			25			
H5431	007	0	1	01	01	H5431_007_0	4	1	Preferred Generic	1	4	001000	1	2	000010010010000000000100				30			30													30		31													0.00								0.00																												0.00					0.00							
H5431	007	0	1	01	01	H5431_007_0	4	2	Non-Preferred Generic	1	4	000100	1	2	000010010010000000000100				30			30													30		31													0.00								10.00																												10.00					10.00							
H5431	007	0	1	01	01	H5431_007_0	4	5	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													200.00	25							200.00	33																										33				33			33			
H5431	007	0	1	01	01	H5431_007_0	4	6	Supplemental Brand and Generic Drugs	1	4	010010	2	2	100010010010000000000101				30			30													30		31		31	14										0.00								10.00																												10.00					10.00			10.00				
H5431	007	0	1	01	01	H5431_007_0	4	3	Preferred Brand	1	4	000001	1	2	100010010010000000000001				30			30													30				31	14										0.00								10.00																												10.00								10.00				
H5431	007	0	1	01	01	H5431_007_0	4	4	Non-Preferred Brand	1	4	100000	1	2	100010010010000000000001				30			30													30				31	14										10.00								50.00																												50.00								50.00				
H5431	008	0	1	01	01	H5431_008_0	4	6	Supplemental Brand and Generic Drugs	1	4	010010	2	2	100010010010000000000101				30			30													30		31		31	14										0.00								10.00																												10.00					10.00			10.00				
H5431	008	0	1	01	01	H5431_008_0	4	1	Preferred Generic	1	4	001000	1	2	000010010010000000000100				30			30													30		31													0.00								0.00																												0.00					0.00							
H5431	008	0	1	01	01	H5431_008_0	4	5	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													200.00	25							200.00	33																										33				33			33			
H5431	008	0	1	01	01	H5431_008_0	4	4	Non-Preferred Brand	1	4	100000	1	2	100010010010000000000001				30			30													30				31	14										15.00								50.00																												50.00								50.00				
H5431	008	0	1	01	01	H5431_008_0	4	3	Preferred Brand	1	4	000001	1	2	100010010010000000000001				30			30													30				31	14										0.00								10.00																												10.00								10.00				
H5431	008	0	1	01	01	H5431_008_0	4	2	Non-Preferred Generic	1	4	000100	1	2	000010010010000000000100				30			30													30		31													0.00								10.00																												10.00					10.00							
H5433	001	0	1	01	01	H5433_001_0	6	1	Preferred Generic	1	4	001000	1	2	010100000001000000000100	30		90							1											29	31					0.00		0.00																																											0.00				0.00							
H5433	001	0	1	01	01	H5433_001_0	6	2	Preferred Brand	1	4	010001	1	2	110100000001000000000101	30		90							1											29	31		31	14		0.00		0.00																																											0.00				0.00			0.00				
H5433	001	0	1	01	01	H5433_001_0	6	3	Non-Preferred Brand	1	4	100000	1	2	110100000001000000000001	30		90							1											29			31	14		0.00		0.00																																											0.00							0.00				
H5433	001	0	1	01	01	H5433_001_0	6	1	Preferred Generic	3	4	001000	1	2	010100000001000000000100	30		90							1											29	31					0.00		0.00																																											0.00				0.00					1		
H5434	002	0	1	04	01	H5434_002_0	10	5	Specialty Tier	1	3	100101		1	110100000010101000000111	31		90							1	31		90							31		31	14	31	14					1602.51	33		33																					33		33																	33				33			33			
H5434	002	0	1	04	01	H5434_002_0	10	4	Non-Preferred Brand	1	3	100000		2	110100000010101000000001	31		90							1	31		90							31				31	14		95.00		285.00																						95.00		285.00																		95.00								95.00				
H5434	002	0	1	04	01	H5434_002_0	10	3	Preferred Brand	1	3	000001		2	110100000010101000000001	31		90							1	31		90							31				31	14		45.00		135.00																						45.00		135.00																		45.00								45.00				
H5434	002	0	1	04	01	H5434_002_0	10	2	Non-Preferred Generic	1	3	000100		2	010100000010101000000110	31		90							1	31		90							31		31	14				17.00		51.00																						8.00		24.00																		17.00					17.00							
H5434	002	0	1	04	01	H5434_002_0	10	1	Preferred Generic	1	3	001000		2	010100000010101000000110	31		90							1	31		90							31		31	14				10.00		30.00																						0.00		0.00																		10.00					10.00							
H5435	014	0	1	09	04	H5435_014_0	8	1	Preferred Generic	1	3	001000		2	010100000010000001001100	31		90							1						90			90	31		31					4.00		12.00																															8.00							12.00				4.00					4.00							
H5435	014	0	1	09	04	H5435_014_0	8	2	Non-Preferred Generic	1	3	000100		2	010100000010000001001100	31		90							1						90			90	31		31					10.00		30.00																															20.00							30.00				10.00					10.00							
H5435	014	0	1	09	04	H5435_014_0	8	3	Preferred Brand	1	3	010001		2	110100000010000001001101	31		90							1						90			90	31		31		31	14		44.00		132.00																															122.00							132.00				44.00					44.00			44.00				
H5435	014	0	1	09	04	H5435_014_0	8	5	Specialty Tier	1	3	010010		1	110100000010000001001101	31		90							1						90			90	31		31		31	14					526.00	33		33																														33							33			33				33			33			
H5435	014	0	1	09	04	H5435_014_0	8	4	Non-Preferred Brand	1	3	100100		2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H5435	024	0	1	09	04	H5435_024_0	8	1	Preferred Generic	1	3	001000		2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H5435	024	0	1	09	04	H5435_024_0	8	2	Non-Preferred Generic	1	3	000100		2	010100000010000001001100	31		90							1						90			90	31		31					10.00		30.00																															20.00							30.00				10.00					10.00							
H5435	024	0	1	09	04	H5435_024_0	8	3	Preferred Brand	1	3	010001		2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H5435	024	0	1	09	04	H5435_024_0	8	4	Non-Preferred Brand	1	3	100100		2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H5435	024	0	1	09	04	H5435_024_0	8	5	Specialty Tier	1	3	010010		1	110100000010000001001101	31		90							1						90			90	31		31		31	14					492.00	33		33																														33							33			33				33			33			
H5439	001	0	1	04	01	H5439_001_0	5	4	Non-Preferred Brand	1	3	100000		2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		95.00	190.00	285.00																													95.00	190.00	275.00					95.00	190.00	285.00				95.00								95.00				
H5439	001	0	1	04	01	H5439_001_0	5	3	Preferred Brand	1	3	000001		2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		45.00	90.00	135.00																													45.00	90.00	125.00					45.00	90.00	135.00				45.00								45.00				
H5439	001	0	1	04	01	H5439_001_0	5	2	Non-Preferred Generic	1	3	000100		2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				25.00	50.00	75.00																													25.00	50.00	50.00					25.00	50.00	75.00				25.00					25.00							
H5439	001	0	1	04	01	H5439_001_0	5	1	Preferred Generic	1	3	001000		2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				7.00	14.00	21.00																													7.00	14.00	14.00					7.00	14.00	21.00				7.00					7.00							
H5439	001	0	1	04	01	H5439_001_0	5	5	Specialty Tier	1	3	010010		1	111100000010000111111111	30	60	90							1				30	60	90	30	60	90	30		34	14	34	14					876.00	33	33	33																												33	33	33					33	33	33			33				33			33			
H5439	002	0	1	04	01	H5439_002_0	5	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		95.00	190.00	285.00																													95.00	190.00	275.00					95.00	190.00	285.00				95.00								95.00				
H5439	002	0	1	04	01	H5439_002_0	5	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		45.00	90.00	135.00																													45.00	90.00	125.00					45.00	90.00	135.00				45.00								45.00				
H5439	002	0	1	04	01	H5439_002_0	5	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				20.00	40.00	60.00																													20.00	40.00	40.00					20.00	40.00	60.00				20.00					20.00							
H5439	002	0	1	04	01	H5439_002_0	5	1	Preferred Generic	1	4	001000	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				3.00	6.00	9.00																													3.00	6.00	6.00					3.00	6.00	9.00				3.00					3.00							
H5439	002	0	1	04	01	H5439_002_0	5	5	Specialty Tier	1	4	010010	1	1	111100000010000111111111	30	60	90							1				30	60	90	30	60	90	30		34	14	34	14					732.00	33	33	33																												33	33	33					33	33	33			33				33			33			
H5470	002	0	1	04	01	H5470_002_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H5470	002	0	1	04	01	H5470_002_0	5	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H5470	002	0	1	04	01	H5470_002_0	5	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1058.00	33																														33							33					33				33			33	2	3	
H5470	002	0	1	04	01	H5470_002_0	5	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		83.00		249.00																													83.00		239.00					83.00		249.00				83.00					83.00			83.00		2	3	
H5470	002	0	1	04	01	H5470_002_0	5	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H5470	002	0	1	04	01	H5470_002_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00		2	3	1
H5470	002	0	1	04	01	H5470_002_0	5	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					959.00	33																														33							33					33				33			33			
H5470	002	0	1	04	01	H5470_002_0	5	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		83.00		249.00																													83.00		239.00					83.00		249.00				83.00					83.00			83.00				
H5470	005	0	1	04	01	H5470_005_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H5470	005	0	1	04	01	H5470_005_0	5	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H5470	005	0	1	04	01	H5470_005_0	5	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H5470	005	0	1	04	01	H5470_005_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H5470	005	0	1	04	01	H5470_005_0	5	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					692.00	33																														33							33					33				33			33			
H5470	005	0	1	04	01	H5470_005_0	5	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H5470	005	0	1	04	01	H5470_005_0	5	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H5470	005	0	1	04	01	H5470_005_0	5	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					758.00	33																														33							33					33				33			33	2	3	
H5471	001	0	1	01	01	H5471_001_0	5	1	Preferred Generic	1	4	001000	3	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5471	001	0	1	01	01	H5471_001_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5471	001	0	1	01	01	H5471_001_0	5	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		45.00		135.00																								135.00																		45.00								45.00				
H5471	001	0	1	01	01	H5471_001_0	5	4	Non-Preferred Brand	1	4	100000	1	2	110000000010000000000001	30																			30				31	14		75.00																																												75.00								75.00				
H5471	001	0	1	01	01	H5471_001_0	5	5	Specialty Tier	1	4	101101	1	1	110000000010000000000111	30																			30		31	14	31	14					467.69	33																																										33				33			33			
H5471	001	0	1	01	01	H5471_001_0	5	1	Preferred Generic	3	4	001000	3	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H5471	001	0	1	01	01	H5471_001_0	5	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H5471	002	0	1	01	01	H5471_002_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5471	002	0	1	01	01	H5471_002_0	10	1	Preferred Generic	1	4	001000	3	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5471	002	0	1	01	01	H5471_002_0	10	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00				
H5471	002	0	1	01	01	H5471_002_0	10	4	Non-Preferred Brand	1	4	100000	1	2	110000000010000000000001	30																			30				31	14		10.00																																												10.00								10.00				
H5471	002	0	1	01	01	H5471_002_0	10	5	Specialty Tier	1	4	101101	1	1	110000000010000000000111	30																			30		31	14	31	14					516.74	33																																										33				33			33			
H5471	003	0	1	02	01	H5471_003_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		15.00		45.00																								45.00																		15.00								15.00				
H5471	003	0	1	02	01	H5471_003_0	6	1	Preferred Generic	1	4	001000	3	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5471	003	0	1	02	01	H5471_003_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5471	003	0	1	02	01	H5471_003_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110000000010000000000001	30																			30				31	14		30.00																																												30.00								30.00				
H5471	003	0	1	02	01	H5471_003_0	6	5	Specialty Tier	1	4	101101	1	1	110000000010000000000111	30																			30		31	14	31	14					571.58	33																																										33				33			33			
H5471	003	0	1	02	01	H5471_003_0	6	1	Preferred Generic	3	4	001000	3	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H5471	003	0	1	02	01	H5471_003_0	6	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H5471	004	0	1	01	01	H5471_004_0	5	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H5471	004	0	1	01	01	H5471_004_0	5	4	Non-Preferred Brand	1	4	100000	1	2	110000000010000000000001	30																			30				31	14		45.00																																												45.00								45.00				
H5471	004	0	1	01	01	H5471_004_0	5	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		30.00		90.00																								90.00																		30.00								30.00				
H5471	004	0	1	01	01	H5471_004_0	5	1	Preferred Generic	3	4	001000	3	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H5471	004	0	1	01	01	H5471_004_0	5	5	Specialty Tier	1	4	101101	1	1	110000000010000000000111	30																			30		31	14	31	14					582.01	33																																										33				33			33			
H5471	004	0	1	01	01	H5471_004_0	5	1	Preferred Generic	1	4	001000	3	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5471	004	0	1	01	01	H5471_004_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5471	005	0	1	01	01	H5471_005_0	7	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H5471	005	0	1	01	01	H5471_005_0	7	1	Preferred Generic	3	4	001000	3	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H5471	005	0	1	01	01	H5471_005_0	7	5	Specialty Tier	1	4	101101	1	1	110000000010000000000111	30																			30		31	14	31	14					497.21	33																																										33				33			33			
H5471	005	0	1	01	01	H5471_005_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110000000010000000000001	30																			30				31	14		55.00																																												55.00								55.00				
H5471	005	0	1	01	01	H5471_005_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		15.00		45.00																								45.00																		15.00								15.00				
H5471	005	0	1	01	01	H5471_005_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5471	005	0	1	01	01	H5471_005_0	7	1	Preferred Generic	1	4	001000	3	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5471	007	0	1	01	01	H5471_007_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5471	007	0	1	01	01	H5471_007_0	5	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		45.00		135.00																								135.00																		45.00								45.00				
H5471	007	0	1	01	01	H5471_007_0	5	4	Non-Preferred Brand	1	4	100000	1	2	110000000010000000000001	30																			30				31	14		75.00																																												75.00								75.00				
H5471	007	0	1	01	01	H5471_007_0	5	5	Specialty Tier	1	4	101101	1	1	110000000010000000000111	30																			30		31	14	31	14					451.17	33																																										33				33			33			
H5471	007	0	1	01	01	H5471_007_0	5	1	Preferred Generic	3	4	001000	3	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H5471	007	0	1	01	01	H5471_007_0	5	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H5471	007	0	1	01	01	H5471_007_0	5	1	Preferred Generic	1	4	001000	3	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5471	008	0	1	01	01	H5471_008_0	4	1	Preferred Generic	1	4	001000	3	2	010000000010000000000110	30																			30		31	14				0.00																																												0.00					0.00							
H5471	008	0	1	01	01	H5471_008_0	4	2	Non-Preferred Generic	1	4	000100	1	2	010000000010000000000110	30																			30		31	14				0.00																																												0.00					0.00							
H5471	008	0	1	01	01	H5471_008_0	4	3	Preferred Brand	1	4	000001	1	2	110000000010000000000001	30																			30				31	14		10.00																																												10.00								10.00				
H5471	008	0	1	01	01	H5471_008_0	4	4	Non-Preferred Brand	1	4	100000	1	2	110000000010000000000001	30																			30				31	14		25.00																																												25.00								25.00				
H5471	008	0	1	01	01	H5471_008_0	4	5	Specialty Tier	1	4	101101	1	1	110000000010000000000111	30																			30		31	14	31	14					394.29	33																																										33				33			33			
H5471	008	0	1	01	01	H5471_008_0	4	2	Non-Preferred Generic	3	4	000100	1	2	010000000010000000000110	30																			30		31	14				0.00																																												0.00					0.00					1		
H5471	008	0	1	01	01	H5471_008_0	4	1	Preferred Generic	3	4	001000	3	2	010000000010000000000110	30																			30		31	14				0.00																																												0.00					0.00					1		
H5471	009	0	1	01	01	H5471_009_0	5	1	Preferred Generic	1	4	001000	3	2	010000000010000000000110	30																			30		31	14				0.00																																												0.00					0.00							
H5471	009	0	1	01	01	H5471_009_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010000000010000000000110	30																			30		31	14				0.00																																												0.00					0.00							
H5471	009	0	1	01	01	H5471_009_0	5	3	Preferred Brand	1	4	000001	1	2	110000000010000000000001	30																			30				31	14		10.00																																												10.00								10.00				
H5471	009	0	1	01	01	H5471_009_0	5	4	Non-Preferred Brand	1	4	100000	1	2	110000000010000000000001	30																			30				31	14		25.00																																												25.00								25.00				
H5471	009	0	1	01	01	H5471_009_0	5	5	Specialty Tier	1	4	101101	1	1	110000000010000000000111	30																			30		31	14	31	14					396.10	33																																										33				33			33			
H5471	009	0	1	01	01	H5471_009_0	5	1	Preferred Generic	3	4	001000	3	2	010000000010000000000110	30																			30		31	14				0.00																																												0.00					0.00					1		
H5471	009	0	1	01	01	H5471_009_0	5	2	Non-Preferred Generic	3	4	000100	1	2	010000000010000000000110	30																			30		31	14				0.00																																												0.00					0.00					1		
H5471	010	0	1	01	01	H5471_010_0	4	1	Preferred Generic	1	4	001000	3	2	010000000010000000000110	30																			30		31	14				0.00																																												0.00					0.00							
H5471	010	0	1	01	01	H5471_010_0	4	2	Non-Preferred Generic	1	4	000100	1	2	010000000010000000000110	30																			30		31	14				0.00																																												0.00					0.00							
H5471	010	0	1	01	01	H5471_010_0	4	3	Preferred Brand	1	4	000001	1	2	110000000010000000000001	30																			30				31	14		45.00																																												45.00								45.00				
H5471	010	0	1	01	01	H5471_010_0	4	4	Non-Preferred Brand	1	4	100000	1	2	110000000010000000000001	30																			30				31	14		75.00																																												75.00								75.00				
H5471	010	0	1	01	01	H5471_010_0	4	5	Specialty Tier	1	4	101101	1	1	110000000010000000000111	30																			30		31	14	31	14					364.13	33																																										33				33			33			
H5471	010	0	1	01	01	H5471_010_0	4	1	Preferred Generic	3	4	001000	3	2	010000000010000000000110	30																			30		31	14				0.00																																												0.00					0.00					1		
H5471	010	0	1	01	01	H5471_010_0	4	2	Non-Preferred Generic	3	4	000100	1	2	010000000010000000000110	30																			30		31	14				0.00																																												0.00					0.00					1		
H5471	011	0	1	01	01	H5471_011_0	5	2	Non-Preferred Generic	3	4	000100	1	2	010000000010000000000110	30																			30		31	14				0.00																																												0.00					0.00					1		
H5471	011	0	1	01	01	H5471_011_0	5	1	Preferred Generic	1	4	001000	3	2	010000000010000000000110	30																			30		31	14				0.00																																												0.00					0.00							
H5471	011	0	1	01	01	H5471_011_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010000000010000000000110	30																			30		31	14				0.00																																												0.00					0.00							
H5471	011	0	1	01	01	H5471_011_0	5	3	Preferred Brand	1	4	000001	1	2	110000000010000000000001	30																			30				31	14		45.00																																												45.00								45.00				
H5471	011	0	1	01	01	H5471_011_0	5	4	Non-Preferred Brand	1	4	100000	1	2	110000000010000000000001	30																			30				31	14		75.00																																												75.00								75.00				
H5471	011	0	1	01	01	H5471_011_0	5	5	Specialty Tier	1	4	101101	1	1	110000000010000000000111	30																			30		31	14	31	14					366.65	33																																										33				33			33			
H5471	011	0	1	01	01	H5471_011_0	5	1	Preferred Generic	3	4	001000	3	2	010000000010000000000110	30																			30		31	14				0.00																																												0.00					0.00					1		
H5471	012	0	1	01	01	H5471_012_0	7	1	Preferred Generic	1	4	001000	3	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5471	012	0	1	01	01	H5471_012_0	7	4	Non-Preferred Brand	3	4	100000	1	2	110000000010000000000001	30																			30				31	14		15.00																																												15.00								15.00		2		
H5471	012	0	1	01	01	H5471_012_0	7	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00		2		
H5471	012	0	1	01	01	H5471_012_0	7	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H5471	012	0	1	01	01	H5471_012_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110000000010000000000001	30																			30				31	14		15.00																																												15.00								15.00				
H5471	012	0	1	01	01	H5471_012_0	7	5	Specialty Tier	1	4	101101	1	1	110000000010000000000111	30																			30		31	14	31	14					498.93	33																																										33				33			33			
H5471	012	0	1	01	01	H5471_012_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00				
H5471	012	0	1	01	01	H5471_012_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5471	012	0	1	01	01	H5471_012_0	7	1	Preferred Generic	3	4	001000	3	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H5471	013	0	1	01	01	H5471_013_0	7	1	Preferred Generic	1	4	001000	3	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5471	013	0	1	01	01	H5471_013_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5471	013	0	1	01	01	H5471_013_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110000000010000000000001	30																			30				31	14		75.00																																												75.00								75.00				
H5471	013	0	1	01	01	H5471_013_0	7	5	Specialty Tier	1	4	101101	1	1	110000000010000000000111	30																			30		31	14	31	14					464.82	33																																										33				33			33			
H5471	013	0	1	01	01	H5471_013_0	7	1	Preferred Generic	3	4	001000	3	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H5471	013	0	1	01	01	H5471_013_0	7	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H5471	013	0	1	01	01	H5471_013_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		45.00		135.00																								135.00																		45.00								45.00				
H5471	014	0	1	01	01	H5471_014_0	5	4	Non-Preferred Brand	1	4	100000	1	2	110000000010000000000001	30																			30				31	14		30.00																																												30.00								30.00				
H5471	014	0	1	01	01	H5471_014_0	5	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H5471	014	0	1	01	01	H5471_014_0	5	1	Preferred Generic	3	4	001000	3	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H5471	014	0	1	01	01	H5471_014_0	5	5	Specialty Tier	1	4	101101	1	1	110000000010000000000111	30																			30		31	14	31	14					507.75	33																																										33				33			33			
H5471	014	0	1	01	01	H5471_014_0	5	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		5.00		15.00																								15.00																		5.00								5.00				
H5471	014	0	1	01	01	H5471_014_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5471	014	0	1	01	01	H5471_014_0	5	1	Preferred Generic	1	4	001000	3	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5471	015	0	1	02	01	H5471_015_0	6	1	Preferred Generic	3	4	001000	3	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H5471	015	0	1	02	01	H5471_015_0	6	5	Specialty Tier	1	4	101101	1	1	110000000010000000000111	30																			30		31	14	31	14					546.77	33																																										33				33			33			
H5471	015	0	1	02	01	H5471_015_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110000000010000000000001	30																			30				31	14		40.00																																												40.00								40.00				
H5471	015	0	1	02	01	H5471_015_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		20.00		60.00																								60.00																		20.00								20.00				
H5471	015	0	1	02	01	H5471_015_0	6	1	Preferred Generic	1	4	001000	3	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5471	015	0	1	02	01	H5471_015_0	6	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H5471	015	0	1	02	01	H5471_015_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5471	016	0	1	01	01	H5471_016_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5471	016	0	1	01	01	H5471_016_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		45.00		135.00																								135.00																		45.00								45.00				
H5471	016	0	1	01	01	H5471_016_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110000000010000000000001	30																			30				31	14		60.00																																												60.00								60.00				
H5471	016	0	1	01	01	H5471_016_0	6	5	Specialty Tier	1	4	101101	1	1	110000000010000000000111	30																			30		31	14	31	14					557.56	33																																										33				33			33			
H5471	016	0	1	01	01	H5471_016_0	6	1	Preferred Generic	1	4	001000	3	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5471	017	0	1	01	01	H5471_017_0	4	1	Preferred Generic	1	4	001000	3	2	010000000010000000000110	30																			30		31	14				0.00																																												0.00					0.00							
H5471	017	0	1	01	01	H5471_017_0	4	4	Non-Preferred Brand	1	4	100000	1	2	110000000010000000000001	30																			30				31	14		25.00																																												25.00								25.00				
H5471	017	0	1	01	01	H5471_017_0	4	3	Preferred Brand	1	4	000001	1	2	110000000010000000000001	30																			30				31	14		10.00																																												10.00								10.00				
H5471	017	0	1	01	01	H5471_017_0	4	1	Preferred Generic	3	4	001000	3	2	010000000010000000000110	30																			30		31	14				0.00																																												0.00					0.00					1		
H5471	017	0	1	01	01	H5471_017_0	4	2	Non-Preferred Generic	3	4	000100	1	2	010000000010000000000110	30																			30		31	14				0.00																																												0.00					0.00					1		
H5471	017	0	1	01	01	H5471_017_0	4	2	Non-Preferred Generic	1	4	000100	1	2	010000000010000000000110	30																			30		31	14				0.00																																												0.00					0.00							
H5471	017	0	1	01	01	H5471_017_0	4	5	Specialty Tier	1	4	101101	1	1	110000000010000000000111	30																			30		31	14	31	14					379.81	33																																										33				33			33			
H5471	018	0	1	01	01	H5471_018_0	4	4	Non-Preferred Brand	1	4	100000	1	2	110000000010000000000001	30																			30				31	14		25.00																																												25.00								25.00				
H5471	018	0	1	01	01	H5471_018_0	4	5	Specialty Tier	1	4	101101	1	1	110000000010000000000111	30																			30		31	14	31	14					380.04	33																																										33				33			33			
H5471	018	0	1	01	01	H5471_018_0	4	1	Preferred Generic	3	4	001000	3	2	010000000010000000000110	30																			30		31	14				0.00																																												0.00					0.00					1		
H5471	018	0	1	01	01	H5471_018_0	4	2	Non-Preferred Generic	3	4	000100	1	2	010000000010000000000110	30																			30		31	14				0.00																																												0.00					0.00					1		
H5471	018	0	1	01	01	H5471_018_0	4	1	Preferred Generic	1	4	001000	3	2	010000000010000000000110	30																			30		31	14				0.00																																												0.00					0.00							
H5471	018	0	1	01	01	H5471_018_0	4	3	Preferred Brand	1	4	000001	1	2	110000000010000000000001	30																			30				31	14		10.00																																												10.00								10.00				
H5471	018	0	1	01	01	H5471_018_0	4	2	Non-Preferred Generic	1	4	000100	1	2	010000000010000000000110	30																			30		31	14				0.00																																												0.00					0.00							
H5471	019	0	1	01	01	H5471_019_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		5.00		15.00																								15.00																		5.00								5.00				
H5471	019	0	1	01	01	H5471_019_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5471	019	0	1	01	01	H5471_019_0	6	1	Preferred Generic	1	4	001000	3	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5471	019	0	1	01	01	H5471_019_0	6	4	Non-Preferred Brand	3	4	100000	1	2	110000000010000000000001	30																			30				31	14		30.00																																												30.00								30.00		2		
H5471	019	0	1	01	01	H5471_019_0	6	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		5.00		15.00																								15.00																		5.00								5.00		2		
H5471	019	0	1	01	01	H5471_019_0	6	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H5471	019	0	1	01	01	H5471_019_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110000000010000000000001	30																			30				31	14		30.00																																												30.00								30.00				
H5471	019	0	1	01	01	H5471_019_0	6	5	Specialty Tier	1	4	101101	1	1	110000000010000000000111	30																			30		31	14	31	14					477.72	33																																										33				33			33			
H5471	019	0	1	01	01	H5471_019_0	6	1	Preferred Generic	3	4	001000	3	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H5471	020	0	1	01	01	H5471_020_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5471	020	0	1	01	01	H5471_020_0	7	1	Preferred Generic	1	4	001000	3	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5471	020	0	1	01	01	H5471_020_0	7	5	Specialty Tier	1	4	101101	1	1	110000000010000000000111	30																			30		31	14	31	14					462.80	33																																										33				33			33			
H5471	020	0	1	01	01	H5471_020_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		15.00		45.00																								45.00																		15.00								15.00				
H5471	020	0	1	01	01	H5471_020_0	7	4	Non-Preferred Brand	3	4	100000	1	2	110000000010000000000001	30																			30				31	14		55.00																																												55.00								55.00		2		
H5471	020	0	1	01	01	H5471_020_0	7	1	Preferred Generic	3	4	001000	3	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H5471	020	0	1	01	01	H5471_020_0	7	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H5471	020	0	1	01	01	H5471_020_0	7	3	Preferred Brand	3	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		15.00		45.00																								45.00																		15.00								15.00		2		
H5471	020	0	1	01	01	H5471_020_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110000000010000000000001	30																			30				31	14		55.00																																												55.00								55.00				
H5471	021	0	1	01	01	H5471_021_0	5	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		15.00		45.00																								45.00																		15.00								15.00				
H5471	021	0	1	01	01	H5471_021_0	5	5	Specialty Tier	1	4	101101	1	1	110000000010000000000111	30																			30		31	14	31	14					497.77	33																																										33				33			33			
H5471	021	0	1	01	01	H5471_021_0	5	1	Preferred Generic	1	4	001000	3	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5471	021	0	1	01	01	H5471_021_0	5	1	Preferred Generic	3	4	001000	3	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H5471	021	0	1	01	01	H5471_021_0	5	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H5471	021	0	1	01	01	H5471_021_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5471	021	0	1	01	01	H5471_021_0	5	4	Non-Preferred Brand	1	4	100000	1	2	110000000010000000000001	30																			30				31	14		55.00																																												55.00								55.00				
H5471	022	0	1	01	01	H5471_022_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		45.00		135.00																								135.00																		45.00								45.00				
H5471	022	0	1	01	01	H5471_022_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110000000010000000000001	30																			30				31	14		75.00																																												75.00								75.00				
H5471	022	0	1	01	01	H5471_022_0	6	5	Specialty Tier	1	4	101101	1	1	110000000010000000000111	30																			30		31	14	31	14					513.67	33																																										33				33			33			
H5471	022	0	1	01	01	H5471_022_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				15.00		45.00																								45.00																		15.00					15.00							
H5471	022	0	1	01	01	H5471_022_0	6	1	Preferred Generic	1	4	001000	3	2	010100000010001000000110	30		90							2			90							30		31	14				2.00		6.00																								6.00																		2.00					2.00							
H5471	024	0	1	01	01	H5471_024_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				15.00		45.00																								45.00																		15.00					15.00							
H5471	024	0	1	01	01	H5471_024_0	6	1	Preferred Generic	1	4	001000	3	2	010100000010001000000110	30		90							2			90							30		31	14				2.00		6.00																								6.00																		2.00					2.00							
H5471	024	0	1	01	01	H5471_024_0	6	5	Specialty Tier	1	4	101101	1	1	110000000010000000000111	30																			30		31	14	31	14					513.05	33																																										33				33			33			
H5471	024	0	1	01	01	H5471_024_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		45.00		135.00																								135.00																		45.00								45.00				
H5471	024	0	1	01	01	H5471_024_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110000000010000000000001	30																			30				31	14		65.00																																												65.00								65.00				
H5507	001	0	1	04	01	H5507_001_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					622.00	33		33																														33							33			33				33			33			
H5507	001	0	1	04	01	H5507_001_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		92.00		276.00																															266.00							276.00				92.00					92.00			92.00				
H5507	001	0	1	04	01	H5507_001_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		44.00		132.00																															122.00							132.00				44.00					44.00			44.00				
H5507	001	0	1	04	01	H5507_001_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					5.00		15.00																															0.00							15.00				5.00					5.00							
H5507	001	0	1	04	01	H5507_001_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00							
H5508	001	0	1	04	01	H5508_001_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					8.00		24.00																						8.00		16.00																		8.00					8.00							
H5508	001	0	1	04	01	H5508_001_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					8.00		24.00																						8.00		16.00																		8.00					8.00							
H5508	001	0	1	04	01	H5508_001_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		45.00		135.00																						45.00		90.00																		45.00								45.00				
H5508	001	0	1	04	01	H5508_001_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		80.00		240.00																						80.00		160.00																		80.00								80.00				
H5508	001	0	1	04	01	H5508_001_0	7	5	Specialty Tier	1	4	000010	1	1	110100000010101000000001	30		90							2	30		90							30				31	14					33.00	33		33																					33		33																	33							33			
H5508	001	0	1	04	01	H5508_001_0	7	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					8.00		24.00																						8.00		16.00																		8.00					8.00					1		
H5508	001	0	1	04	01	H5508_001_0	7	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					8.00		24.00																						8.00		16.00																		8.00					8.00					1		
H5508	005	0	1	04	01	H5508_005_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					8.00		24.00																						8.00		16.00																		8.00					8.00							
H5508	005	0	1	04	01	H5508_005_0	7	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					8.00		24.00																						8.00		16.00																		8.00					8.00					1		
H5508	005	0	1	04	01	H5508_005_0	7	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					8.00		24.00																						8.00		16.00																		8.00					8.00					1		
H5508	005	0	1	04	01	H5508_005_0	7	5	Specialty Tier	1	4	000010	1	1	110100000010101000000001	30		90							2	30		90							30				31	14					33.00	33		33																					33		33																	33							33			
H5508	005	0	1	04	01	H5508_005_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		80.00		240.00																						80.00		160.00																		80.00								80.00				
H5508	005	0	1	04	01	H5508_005_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		45.00		135.00																						45.00		90.00																		45.00								45.00				
H5508	005	0	1	04	01	H5508_005_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					8.00		24.00																						8.00		16.00																		8.00					8.00							
H5508	006	0	1	04	01	H5508_006_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		45.00		135.00																						45.00		90.00																		45.00								45.00				
H5508	006	0	1	04	01	H5508_006_0	7	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					8.00		24.00																						8.00		16.00																		8.00					8.00					1		
H5508	006	0	1	04	01	H5508_006_0	7	5	Specialty Tier	1	4	000010	1	1	110100000010101000000001	30		90							2	30		90							30				31	14					33.00	33		33																					33		33																	33							33			
H5508	006	0	1	04	01	H5508_006_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		80.00		240.00																						80.00		160.00																		80.00								80.00				
H5508	006	0	1	04	01	H5508_006_0	7	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					8.00		24.00																						8.00		16.00																		8.00					8.00					1		
H5508	006	0	1	04	01	H5508_006_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					8.00		24.00																						8.00		16.00																		8.00					8.00							
H5508	006	0	1	04	01	H5508_006_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					8.00		24.00																						8.00		16.00																		8.00					8.00							
H5509	001	0	1	04	01	H5509_001_0	9	4	Specialty Tier	1	4	010001	1	1	110000000010000000000101	30																			30		31		31	14					732.47	33																																										33				33			33			
H5509	001	0	1	04	01	H5509_001_0	9	3	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		80.00		240.00																						80.00		240.00																		80.00					80.00			80.00				
H5509	001	0	1	04	01	H5509_001_0	9	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		45.00		135.00																						45.00		135.00																		45.00								45.00				
H5509	001	0	1	04	01	H5509_001_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					6.00		18.00																						6.00		18.00																		6.00					6.00							
H5509	003	0	1	04	01	H5509_003_0	10	3	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		80.00		240.00																						80.00		240.00																		80.00					80.00			80.00				
H5509	003	0	1	04	01	H5509_003_0	10	4	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					524.01	33																																										33				33			33			
H5509	003	0	1	04	01	H5509_003_0	10	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		45.00		135.00																						45.00		135.00																		45.00								45.00				
H5509	003	0	1	04	01	H5509_003_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					6.00		18.00																						0.00		0.00																		6.00					6.00							
H5509	010	0	1	04	01	H5509_010_0	8	4	Specialty Tier	1	4	010001	1	1	100010010010000000000101				30			30													30		31		31	14													924.11	33							924.11	33																										33				33			33			
H5509	010	0	1	04	01	H5509_010_0	8	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													5.00		15.00						6.00		18.00						5.00		15.00																		6.00					6.00							
H5509	010	0	1	04	01	H5509_010_0	8	2	Preferred Brand	1	4	000001	1	2	100010110110101000000001				30		90	30		90	2	30		90							30				31	14										40.00		120.00						40.00		120.00						40.00		120.00																		40.00								40.00				
H5509	010	0	1	04	01	H5509_010_0	8	3	Non-Preferred Brand	1	4	100100	1	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										80.00		240.00						80.00		240.00						80.00		240.00																		80.00					80.00			80.00				
H5509	011	0	1	04	01	H5509_011_0	10	4	Specialty Tier	1	4	010001	1	1	110000000010000000000101	30																			30		31		31	14					782.06	33																																										33				33			33			
H5509	011	0	1	04	01	H5509_011_0	10	3	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		80.00		240.00																						80.00		240.00																		80.00					80.00			80.00				
H5509	011	0	1	04	01	H5509_011_0	10	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		45.00		135.00																						45.00		135.00																		45.00								45.00				
H5509	011	0	1	04	01	H5509_011_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					6.00		18.00																						6.00		18.00																		6.00					6.00							
H5509	012	0	1	04	01	H5509_012_0	9	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		40.00		120.00																						40.00		120.00																		40.00								40.00				
H5509	012	0	1	04	01	H5509_012_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					6.00		18.00																						6.00		18.00																		6.00					6.00							
H5509	012	0	1	04	01	H5509_012_0	9	3	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		80.00		240.00																						80.00		240.00																		80.00					80.00			80.00				
H5509	012	0	1	04	01	H5509_012_0	9	4	Specialty Tier	1	4	010001	1	1	110000000010000000000101	30																			30		31		31	14					816.75	33																																										33				33			33			
H5509	016	0	1	04	01	H5509_016_0	9	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		40.00		120.00																						40.00		120.00																		40.00								40.00				
H5509	016	0	1	04	01	H5509_016_0	9	3	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		80.00		240.00																						80.00		240.00																		80.00					80.00			80.00				
H5509	016	0	1	04	01	H5509_016_0	9	4	Specialty Tier	1	4	010001	1	1	110000000010000000000101	30																			30		31		31	14					773.96	33																																										33				33			33			
H5509	016	0	1	04	01	H5509_016_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					6.00		18.00																						6.00		18.00																		6.00					6.00							
H5509	017	0	1	04	01	H5509_017_0	9	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													781.55	33							781.55	33																										33				33			33			
H5509	017	0	1	04	01	H5509_017_0	9	2	Preferred Brand	1	4	000001	1	2	100010110110101000000001				30		90	30		90	2	30		90							30				31	14										40.00		120.00						45.00		135.00						40.00		120.00																		45.00								45.00				
H5509	017	0	1	04	01	H5509_017_0	9	3	Non-Preferred Brand	1	4	100100	1	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										80.00		240.00						85.00		255.00						80.00		240.00																		85.00					85.00			85.00				
H5509	017	0	1	04	01	H5509_017_0	9	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													6.00		18.00						7.00		21.00						0.00		0.00																		7.00					7.00							
H5509	018	0	1	04	01	H5509_018_0	12	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													4.00		12.00						6.00		18.00						0.00		0.00																		6.00					6.00							
H5509	018	0	1	04	01	H5509_018_0	12	2	Non-Preferred Generic	1	4	000100	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													6.00		18.00						6.00		18.00						6.00		18.00																		6.00					6.00							
H5509	018	0	1	04	01	H5509_018_0	12	4	Non-Preferred Brand	1	4	100100	1	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										80.00		240.00						85.00		255.00						80.00		240.00																		85.00					85.00			85.00				
H5509	018	0	1	04	01	H5509_018_0	12	3	Preferred Brand	1	4	000001	1	2	100010110110101000000001				30		90	30		90	2	30		90							30				31	14										40.00		120.00						45.00		135.00						40.00		120.00																		45.00								45.00				
H5509	018	0	1	04	01	H5509_018_0	12	5	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													737.89	33							737.89	33																										33				33			33			
H5516	001	0	1	04	01	H5516_001_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00							
H5516	001	0	1	04	01	H5516_001_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H5516	001	0	1	04	01	H5516_001_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					683.00	33		33																														33							33			33				33			33			
H5516	001	0	1	04	01	H5516_001_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H5516	001	0	1	04	01	H5516_001_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H5520	002	0	1	04	01	H5520_002_0	5	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		95.00	190.00	285.00																													95.00	190.00	238.00					95.00	190.00	285.00				95.00								95.00				
H5520	002	0	1	04	01	H5520_002_0	5	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		42.00	84.00	126.00																													42.00	84.00	84.00					42.00	84.00	126.00				42.00								42.00				
H5520	002	0	1	04	01	H5520_002_0	5	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				15.00	30.00	45.00																													15.00	30.00	30.00					15.00	30.00	45.00				15.00					15.00							
H5520	002	0	1	04	01	H5520_002_0	5	1	Preferred Generic	1	4	001000	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				3.00	6.00	9.00																													3.00	6.00	6.00					3.00	6.00	9.00				3.00					3.00							
H5520	002	0	1	04	01	H5520_002_0	5	5	Specialty Tier	1	4	010010	1	1	111100000010000111111111	30	60	90							1				30	60	90	30	60	90	30		34	14	34	14					549.00	33	33	33																												33	33	33					33	33	33			33				33			33			
H5520	004	0	1	04	01	H5520_004_0	5	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		95.00	190.00	285.00																													95.00	190.00	238.00					95.00	190.00	285.00				95.00								95.00				
H5520	004	0	1	04	01	H5520_004_0	5	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		42.00	84.00	126.00																													42.00	84.00	84.00					42.00	84.00	126.00				42.00								42.00				
H5520	004	0	1	04	01	H5520_004_0	5	5	Specialty Tier	1	4	010010	1	1	111100000010000111111111	30	60	90							1				30	60	90	30	60	90	30		34	14	34	14					313.00	33	33	33																												33	33	33					33	33	33			33				33			33			
H5520	004	0	1	04	01	H5520_004_0	5	1	Preferred Generic	1	4	001000	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				3.00	6.00	9.00																													3.00	6.00	6.00					3.00	6.00	9.00				3.00					3.00							
H5520	004	0	1	04	01	H5520_004_0	5	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				15.00	30.00	45.00																													15.00	30.00	30.00					15.00	30.00	45.00				15.00					15.00							
H5520	005	0	1	04	01	H5520_005_0	5	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		95.00	190.00	285.00																													95.00	190.00	238.00					95.00	190.00	285.00				95.00								95.00				
H5520	005	0	1	04	01	H5520_005_0	5	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00				45.00								45.00				
H5520	005	0	1	04	01	H5520_005_0	5	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				20.00	40.00	60.00																													20.00	40.00	40.00					20.00	40.00	60.00				20.00					20.00							
H5520	005	0	1	04	01	H5520_005_0	5	1	Preferred Generic	1	4	001000	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				3.00	6.00	9.00																													3.00	6.00	6.00					3.00	6.00	9.00				3.00					3.00							
H5520	005	0	1	04	01	H5520_005_0	5	5	Specialty Tier	1	4	010010	1	1	111100000010000111111111	30	60	90							1				30	60	90	30	60	90	30		34	14	34	14					491.00	33	33	33																												33	33	33					33	33	33			33				33			33			
H5520	006	0	1	04	01	H5520_006_0	5	5	Specialty Tier	1	4	010010	1	1	111100000010000111111111	30	60	90							1				30	60	90	30	60	90	30		34	14	34	14					430.00	33	33	33																												33	33	33					33	33	33			33				33			33			
H5520	006	0	1	04	01	H5520_006_0	5	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		95.00	190.00	285.00																													95.00	190.00	238.00					95.00	190.00	285.00				95.00								95.00				
H5520	006	0	1	04	01	H5520_006_0	5	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00				45.00								45.00				
H5520	006	0	1	04	01	H5520_006_0	5	1	Preferred Generic	1	4	001000	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				3.00	6.00	9.00																													3.00	6.00	6.00					3.00	6.00	9.00				3.00					3.00							
H5520	006	0	1	04	01	H5520_006_0	5	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				20.00	40.00	60.00																													20.00	40.00	40.00					20.00	40.00	60.00				20.00					20.00							
H5520	009	0	1	04	01	H5520_009_0	5	5	Specialty Tier	1	4	010010	1	1	111100000010000111111111	30	60	90							1				30	60	90	30	60	90	30		34	14	34	14					428.00	33	33	33																												33	33	33					33	33	33			33				33			33			
H5520	009	0	1	04	01	H5520_009_0	5	1	Preferred Generic	1	4	001000	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				3.00	6.00	9.00																													3.00	6.00	6.00					3.00	6.00	9.00				3.00					3.00							
H5520	009	0	1	04	01	H5520_009_0	5	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				10.00	20.00	30.00																													10.00	20.00	20.00					10.00	20.00	30.00				10.00					10.00							
H5520	009	0	1	04	01	H5520_009_0	5	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		35.00	70.00	105.00																													35.00	70.00	70.00					35.00	70.00	105.00				35.00								35.00				
H5520	009	0	1	04	01	H5520_009_0	5	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		95.00	190.00	285.00																													95.00	190.00	238.00					95.00	190.00	285.00				95.00								95.00				
H5520	010	0	1	04	01	H5520_010_0	5	5	Specialty Tier	1	4	010010	1	1	111100000010000111111111	30	60	90							1				30	60	90	30	60	90	30		34	14	34	14					730.00	33	33	33																												33	33	33					33	33	33			33				33			33			
H5520	010	0	1	04	01	H5520_010_0	5	1	Preferred Generic	1	4	001000	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				3.00	6.00	9.00																													3.00	6.00	6.00					3.00	6.00	9.00				3.00					3.00							
H5520	010	0	1	04	01	H5520_010_0	5	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				10.00	20.00	30.00																													10.00	20.00	20.00					10.00	20.00	30.00				10.00					10.00							
H5520	010	0	1	04	01	H5520_010_0	5	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		35.00	70.00	105.00																													35.00	70.00	70.00					35.00	70.00	105.00				35.00								35.00				
H5520	010	0	1	04	01	H5520_010_0	5	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		95.00	190.00	285.00																													95.00	190.00	238.00					95.00	190.00	285.00				95.00								95.00				
H5521	012	0	1	04	01	H5521_012_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H5521	012	0	1	04	01	H5521_012_0	6	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H5521	012	0	1	04	01	H5521_012_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H5521	012	0	1	04	01	H5521_012_0	6	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					6.00	12.00	18.00																													6.00	12.00	12.00					6.00	12.00	18.00					6.00				6.00							
H5521	012	0	1	04	01	H5521_012_0	6	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					451.31	33	33	33																												33	33	33					33	33	33				33			33			33			
H5521	013	0	1	04	01	H5521_013_0	6	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					407.71	33	33	33																												33	33	33					33	33	33				33			33			33			
H5521	013	0	1	04	01	H5521_013_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H5521	013	0	1	04	01	H5521_013_0	6	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H5521	013	0	1	04	01	H5521_013_0	6	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					7.00	14.00	21.00																													7.00	14.00	14.00					7.00	14.00	21.00					7.00				7.00							
H5521	013	0	1	04	01	H5521_013_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H5521	015	0	1	04	01	H5521_015_0	7	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					204.80	33	33	33																												33	33	33					33	33	33				33			33			33			
H5521	015	0	1	04	01	H5521_015_0	7	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H5521	015	0	1	04	01	H5521_015_0	7	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H5521	015	0	1	04	01	H5521_015_0	7	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H5521	015	0	1	04	01	H5521_015_0	7	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					7.00	14.00	21.00																													7.00	14.00	14.00					7.00	14.00	21.00					7.00				7.00							
H5521	016	0	1	04	01	H5521_016_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H5521	016	0	1	04	01	H5521_016_0	6	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					299.27	33	33	33																												33	33	33					33	33	33				33			33			33			
H5521	016	0	1	04	01	H5521_016_0	6	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H5521	016	0	1	04	01	H5521_016_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H5521	016	0	1	04	01	H5521_016_0	6	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					7.00	14.00	21.00																													7.00	14.00	14.00					7.00	14.00	21.00					7.00				7.00							
H5521	020	0	1	04	01	H5521_020_0	8	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					7.00	14.00	21.00																													7.00	14.00	14.00					7.00	14.00	21.00					7.00				7.00							
H5521	020	0	1	04	01	H5521_020_0	8	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H5521	020	0	1	04	01	H5521_020_0	8	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H5521	020	0	1	04	01	H5521_020_0	8	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H5521	020	0	1	04	01	H5521_020_0	8	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					134.97	33	33	33																												33	33	33					33	33	33				33			33			33			
H5521	022	0	1	04	01	H5521_022_0	8	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H5521	022	0	1	04	01	H5521_022_0	8	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					389.25	33	33	33																												33	33	33					33	33	33				33			33			33			
H5521	022	0	1	04	01	H5521_022_0	8	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					7.00	14.00	21.00																													7.00	14.00	14.00					7.00	14.00	21.00					7.00				7.00							
H5521	022	0	1	04	01	H5521_022_0	8	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H5521	022	0	1	04	01	H5521_022_0	8	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H5521	027	0	1	04	01	H5521_027_0	6	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					219.47	33	33	33																												33	33	33					33	33	33				33			33			33			
H5521	027	0	1	04	01	H5521_027_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H5521	027	0	1	04	01	H5521_027_0	6	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H5521	027	0	1	04	01	H5521_027_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H5521	027	0	1	04	01	H5521_027_0	6	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					7.00	14.00	21.00																													7.00	14.00	14.00					7.00	14.00	21.00					7.00				7.00							
H5521	028	0	1	04	01	H5521_028_0	6	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					203.21	33	33	33																												33	33	33					33	33	33				33			33			33			
H5521	028	0	1	04	01	H5521_028_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H5521	028	0	1	04	01	H5521_028_0	6	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H5521	028	0	1	04	01	H5521_028_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H5521	028	0	1	04	01	H5521_028_0	6	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					7.00	14.00	21.00																													7.00	14.00	14.00					7.00	14.00	21.00					7.00				7.00							
H5521	033	0	1	04	01	H5521_033_0	6	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					7.00	14.00	21.00																													7.00	14.00	14.00					7.00	14.00	21.00					7.00				7.00							
H5521	033	0	1	04	01	H5521_033_0	6	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					246.12	33	33	33																												33	33	33					33	33	33				33			33			33			
H5521	033	0	1	04	01	H5521_033_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H5521	033	0	1	04	01	H5521_033_0	6	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H5521	033	0	1	04	01	H5521_033_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H5521	036	0	1	04	01	H5521_036_0	7	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H5521	036	0	1	04	01	H5521_036_0	7	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					7.00	14.00	21.00																													7.00	14.00	14.00					7.00	14.00	21.00					7.00				7.00							
H5521	036	0	1	04	01	H5521_036_0	7	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H5521	036	0	1	04	01	H5521_036_0	7	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H5521	036	0	1	04	01	H5521_036_0	7	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					295.70	33	33	33																												33	33	33					33	33	33				33			33			33			
H5521	037	0	1	04	01	H5521_037_0	5	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					228.77	33	33	33																												33	33	33					33	33	33				33			33			33			
H5521	037	0	1	04	01	H5521_037_0	5	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H5521	037	0	1	04	01	H5521_037_0	5	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H5521	037	0	1	04	01	H5521_037_0	5	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H5521	037	0	1	04	01	H5521_037_0	5	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					7.00	14.00	21.00																													7.00	14.00	14.00					7.00	14.00	21.00					7.00				7.00							
H5521	038	0	1	04	01	H5521_038_0	5	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					229.17	33	33	33																												33	33	33					33	33	33				33			33			33			
H5521	038	0	1	04	01	H5521_038_0	5	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					6.00	12.00	18.00																													6.00	12.00	12.00					6.00	12.00	18.00					6.00				6.00							
H5521	038	0	1	04	01	H5521_038_0	5	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H5521	038	0	1	04	01	H5521_038_0	5	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H5521	038	0	1	04	01	H5521_038_0	5	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H5521	038	0	1	04	01	H5521_038_0	5	1	Preferred Generic	3	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					6.00	12.00	18.00																													6.00	12.00	12.00					6.00	12.00	18.00					6.00				6.00					1		
H5521	040	0	1	04	01	H5521_040_0	6	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					330.75	33	33	33																												33	33	33					33	33	33				33			33			33			
H5521	040	0	1	04	01	H5521_040_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H5521	040	0	1	04	01	H5521_040_0	6	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H5521	040	0	1	04	01	H5521_040_0	6	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					6.00	12.00	18.00																													6.00	12.00	12.00					6.00	12.00	18.00					6.00				6.00							
H5521	040	0	1	04	01	H5521_040_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H5522	001	0	1	04	01	H5522_001_0	10	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					216.27	33																																										33				33			33			
H5522	001	0	1	04	01	H5522_001_0	10	4	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		85.00		255.00																						85.00		255.00																		85.00					85.00			85.00				
H5522	001	0	1	04	01	H5522_001_0	10	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		34.00		102.00																						34.00		85.00																		34.00								34.00				
H5522	001	0	1	04	01	H5522_001_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					24.00		72.00																						24.00		60.00																		24.00					24.00							
H5522	001	0	1	04	01	H5522_001_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					5.00		15.00																						5.00		12.50																		5.00					5.00							
H5522	001	0	1	04	01	H5522_001_0	10	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					5.00		15.00																						5.00		12.50																		5.00					5.00					1		
H5522	002	0	1	04	01	H5522_002_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					316.34	33																																										33				33			33			
H5522	002	0	1	04	01	H5522_002_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		85.00		255.00																						85.00		255.00																		85.00					85.00			85.00				
H5522	002	0	1	04	01	H5522_002_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		40.00		120.00																						40.00		100.00																		40.00								40.00				
H5522	002	0	1	04	01	H5522_002_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					23.00		69.00																						23.00		57.50																		23.00					23.00							
H5522	002	0	1	04	01	H5522_002_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					2.00		6.00																						2.00		5.00																		2.00					2.00							
H5522	002	0	1	04	01	H5522_002_0	7	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					2.00		6.00																						2.00		5.00																		2.00					2.00					1		
H5522	004	0	1	04	01	H5522_004_0	5	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					6.00		18.00																						6.00		15.00																		6.00					6.00							
H5522	004	0	1	04	01	H5522_004_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					25.00		75.00																						25.00		62.50																		25.00					25.00							
H5522	004	0	1	04	01	H5522_004_0	5	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		35.00		105.00																						35.00		87.50																		35.00								35.00				
H5522	004	0	1	04	01	H5522_004_0	5	4	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		75.00		225.00																						75.00		225.00																		75.00					75.00			75.00				
H5522	004	0	1	04	01	H5522_004_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					366.66	33																																										33				33			33			
H5522	005	0	1	04	01	H5522_005_0	5	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					4.00		12.00																						4.00		10.00																		4.00					4.00							
H5522	005	0	1	04	01	H5522_005_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					27.00		81.00																						27.00		67.50																		27.00					27.00							
H5522	005	0	1	04	01	H5522_005_0	5	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		37.00		111.00																						37.00		92.50																		37.00								37.00				
H5522	005	0	1	04	01	H5522_005_0	5	4	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		85.00		255.00																						85.00		255.00																		85.00					85.00			85.00				
H5522	005	0	1	04	01	H5522_005_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					360.86	33																																										33				33			33			
H5522	008	0	1	04	01	H5522_008_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		88.00		264.00																						88.00		264.00																		88.00					88.00			88.00				
H5522	008	0	1	04	01	H5522_008_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		37.00		111.00																						37.00		92.50																		37.00								37.00				
H5522	008	0	1	04	01	H5522_008_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					24.00		72.00																						24.00		60.00																		24.00					24.00							
H5522	008	0	1	04	01	H5522_008_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					5.00		15.00																						5.00		12.50																		5.00					5.00							
H5522	008	0	1	04	01	H5522_008_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					312.95	33																																										33				33			33			
H5522	009	0	1	04	01	H5522_009_0	5	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					5.00		15.00																						5.00		12.50																		5.00					5.00							
H5522	009	0	1	04	01	H5522_009_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					24.00		72.00																						24.00		60.00																		24.00					24.00							
H5522	009	0	1	04	01	H5522_009_0	5	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		37.00		111.00																						37.00		92.50																		37.00								37.00				
H5522	009	0	1	04	01	H5522_009_0	5	4	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		88.00		264.00																						88.00		264.00																		88.00					88.00			88.00				
H5522	009	0	1	04	01	H5522_009_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					185.62	33																																										33				33			33			
H5522	013	0	1	04	01	H5522_013_0	5	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		35.00		105.00																						35.00		87.50																		35.00								35.00				
H5522	013	0	1	04	01	H5522_013_0	5	4	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		80.00		240.00																						80.00		240.00																		80.00					80.00			80.00				
H5522	013	0	1	04	01	H5522_013_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					172.81	33																																										33				33			33			
H5522	013	0	1	04	01	H5522_013_0	5	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					6.00		18.00																						6.00		15.00																		6.00					6.00							
H5522	013	0	1	04	01	H5522_013_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					25.00		75.00																						25.00		62.50																		25.00					25.00							
H5522	014	0	1	04	01	H5522_014_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					364.11	33																																										33				33			33			
H5522	014	0	1	04	01	H5522_014_0	5	4	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		80.00		240.00																						80.00		240.00																		80.00					80.00			80.00				
H5522	014	0	1	04	01	H5522_014_0	5	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		38.00		114.00																						38.00		95.00																		38.00								38.00				
H5522	014	0	1	04	01	H5522_014_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					25.00		75.00																						25.00		62.50																		25.00					25.00							
H5522	014	0	1	04	01	H5522_014_0	5	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					6.00		18.00																						6.00		15.00																		6.00					6.00							
H5522	015	0	1	04	01	H5522_015_0	5	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					6.00		18.00																						6.00		15.00																		6.00					6.00							
H5522	015	0	1	04	01	H5522_015_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					25.00		75.00																						25.00		62.50																		25.00					25.00							
H5522	015	0	1	04	01	H5522_015_0	5	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		38.00		114.00																						38.00		95.00																		38.00								38.00				
H5522	015	0	1	04	01	H5522_015_0	5	4	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		80.00		240.00																						80.00		240.00																		80.00					80.00			80.00				
H5522	015	0	1	04	01	H5522_015_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					364.14	33																																										33				33			33			
H5525	004	0	1	04	01	H5525_004_0	4	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H5525	004	0	1	04	01	H5525_004_0	4	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H5525	004	0	1	04	01	H5525_004_0	4	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H5525	004	0	1	04	01	H5525_004_0	4	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					733.00	33																														33							33					33				33			33			
H5525	004	0	1	04	01	H5525_004_0	4	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H5525	004	0	1	04	01	H5525_004_0	4	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H5525	004	0	1	04	01	H5525_004_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H5525	004	0	1	04	01	H5525_004_0	4	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					874.00	33																														33							33					33				33			33	2	3	
H5525	005	0	1	04	01	H5525_005_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H5525	005	0	1	04	01	H5525_005_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H5525	005	0	1	04	01	H5525_005_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H5525	005	0	1	04	01	H5525_005_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					866.00	33																														33							33					33				33			33			
H5525	005	0	1	04	01	H5525_005_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H5525	005	0	1	04	01	H5525_005_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H5525	005	0	1	04	01	H5525_005_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H5525	005	0	1	04	01	H5525_005_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H5525	005	0	1	04	01	H5525_005_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H5525	005	0	1	04	01	H5525_005_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					969.00	33																														33							33					33				33			33	2	3	
H5526	003	0	1	04	01	H5526_003_0	16	4	Non-Preferred Brand	1	4	100000	1	1	110100000001101000000001	30		90							2	30		90								14			31	14					44.14	40		40																					40		33																		40						40			
H5526	003	0	1	04	01	H5526_003_0	16	3	Preferred Brand	1	4	000001	1	2	110100000001101000000001	30		90							2	30		90								14			31	14		45.00		135.00																						45.00		112.50																			45.00							45.00				
H5526	003	0	1	04	01	H5526_003_0	16	5	Specialty Tier	1	4	010010	1	1	110100000001101000000111	30		90							2	30		90								14	31	14	31	14					253.45	32		32																					32		27																		32			32			32			
H5526	003	0	1	04	01	H5526_003_0	16	1	Preferred Generic	1	4	001000	1	2	010100000001101000000110	30		90							2	30		90								14	31	14				0.00		0.00																						0.00		0.00																			0.00				0.00							
H5526	003	0	1	04	01	H5526_003_0	16	2	Non-Preferred Generic	1	4	000100	1	2	010100000001101000000110	30		90							2	30		90								14	31	14				7.25		21.75																						7.25		18.13																			7.25				7.25							
H5526	004	0	1	04	01	H5526_004_0	15	2	Non-Preferred Generic	1	4	000100	1	2	010100000001101000000110	30		90							2	30		90								14	31	14				7.50		22.50																						7.50		18.75																			7.50				7.50							
H5526	004	0	1	04	01	H5526_004_0	15	1	Preferred Generic	1	4	001000	1	2	010100000001101000000110	30		90							2	30		90								14	31	14				0.00		0.00																						0.00		0.00																			0.00				0.00							
H5526	004	0	1	04	01	H5526_004_0	15	3	Preferred Brand	1	4	000001	1	2	110100000001101000000001	30		90							2	30		90								14			31	14		45.00		135.00																						45.00		112.50																			45.00							45.00				
H5526	004	0	1	04	01	H5526_004_0	15	5	Specialty Tier	1	4	010010	1	1	110100000001101000000111	30		90							2	30		90								14	31	14	31	14					783.51	30		30																					30		25																		30			30			30			
H5526	004	0	1	04	01	H5526_004_0	15	4	Non-Preferred Brand	1	4	100000	1	1	110100000001101000000001	30		90							2	30		90								14			31	14					59.04	50		50																					50		42																		50						50			
H5526	013	0	1	04	01	H5526_013_0	14	1	Preferred Generic	1	4	001000	1	2	010100000001101000000110	30		90							2	30		90								14	31	14				0.00		0.00																						0.00		0.00																			0.00				0.00							
H5526	013	0	1	04	01	H5526_013_0	14	2	Non-Preferred Generic	1	4	000100	1	2	010100000001101000000110	30		90							2	30		90								14	31	14				7.50		22.50																						7.50		18.75																			7.50				7.50							
H5526	013	0	1	04	01	H5526_013_0	14	4	Non-Preferred Brand	1	4	100000	1	1	110100000001101000000001	30		90							2	30		90								14			31	14					59.04	50		50																					50		42																		50						50			
H5526	013	0	1	04	01	H5526_013_0	14	3	Preferred Brand	1	4	000001	1	2	110100000001101000000001	30		90							2	30		90								14			31	14		45.00		135.00																						45.00		112.50																			45.00							45.00				
H5526	013	0	1	04	01	H5526_013_0	14	5	Specialty Tier	1	4	010010	1	1	110100000001101000000111	30		90							2	30		90								14	31	14	31	14					783.51	30		30																					30		25																		30			30			30			
H5528	002	0	1	04	01	H5528_002_0	12	2	Preferred Brand	1	4	010001	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		35.00	70.00	70.00																						35.00	70.00	70.00																		35.00					35.00			35.00				
H5528	002	0	1	04	01	H5528_002_0	12	3	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		95.00	190.00	190.00																						95.00	190.00	190.00																		95.00					95.00			95.00				
H5528	002	0	1	04	01	H5528_002_0	12	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					908.84	25	25	25																					25	25	25																	25				25			25			
H5528	002	0	1	04	01	H5528_002_0	12	1	Preferred Generic	1	4	001000	1	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					5.00	10.00	10.00																						5.00	10.00	10.00																		5.00					5.00							
H5528	003	0	1	04	01	H5528_003_0	12	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					793.53	25	25	25																					25	25	25																	25				25			25			
H5528	003	0	1	04	01	H5528_003_0	12	3	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		95.00	190.00	190.00																						95.00	190.00	190.00																		95.00					95.00			95.00				
H5528	003	0	1	04	01	H5528_003_0	12	2	Preferred Brand	1	4	010001	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		35.00	70.00	70.00																						35.00	70.00	70.00																		35.00					35.00			35.00				
H5528	003	0	1	04	01	H5528_003_0	12	1	Preferred Generic	3	4	001000	1	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					5.00	10.00	10.00																						5.00	10.00	10.00																		5.00					5.00					1		
H5528	003	0	1	04	01	H5528_003_0	12	1	Preferred Generic	1	4	001000	1	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					5.00	10.00	10.00																						5.00	10.00	10.00																		5.00					5.00							
H5528	005	0	1	04	01	H5528_005_0	16	1	Preferred Generic	1	4	001000	1	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					5.00	10.00	10.00																						5.00	10.00	10.00																		5.00					5.00							
H5528	005	0	1	04	01	H5528_005_0	16	2	Preferred Brand	1	4	010001	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		35.00	70.00	70.00																						35.00	70.00	70.00																		35.00					35.00			35.00				
H5528	005	0	1	04	01	H5528_005_0	16	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					862.65	25	25	25																					25	25	25																	25				25			25			
H5528	005	0	1	04	01	H5528_005_0	16	3	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		95.00	190.00	190.00																						95.00	190.00	190.00																		95.00					95.00			95.00				
H5528	008	0	1	04	01	H5528_008_0	13	2	Preferred Brand	1	4	010001	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		35.00	70.00	70.00																						35.00	70.00	70.00																		35.00					35.00			35.00				
H5528	008	0	1	04	01	H5528_008_0	13	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					793.53	25	25	25																					25	25	25																	25				25			25			
H5528	008	0	1	04	01	H5528_008_0	13	1	Preferred Generic	3	4	001000	1	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					5.00	10.00	10.00																						5.00	10.00	10.00																		5.00					5.00					1		
H5528	008	0	1	04	01	H5528_008_0	13	3	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		95.00	190.00	190.00																						95.00	190.00	190.00																		95.00					95.00			95.00				
H5528	008	0	1	04	01	H5528_008_0	13	1	Preferred Generic	1	4	001000	1	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					5.00	10.00	10.00																						5.00	10.00	10.00																		5.00					5.00							
H5528	010	0	1	04	01	H5528_010_0	14	1	Preferred Generic	1	4	001000	1	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					5.00	10.00	10.00																						5.00	10.00	10.00																		5.00					5.00							
H5528	010	0	1	04	01	H5528_010_0	14	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					796.94	25	25	25																					25	25	25																	25				25			25			
H5528	010	0	1	04	01	H5528_010_0	14	3	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		95.00	190.00	190.00																						95.00	190.00	190.00																		95.00					95.00			95.00				
H5528	010	0	1	04	01	H5528_010_0	14	2	Preferred Brand	1	4	010001	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		35.00	70.00	70.00																						35.00	70.00	70.00																		35.00					35.00			35.00				
H5528	011	0	1	04	01	H5528_011_0	13	1	Preferred Generic	1	4	001000	1	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					5.00	10.00	10.00																						5.00	10.00	10.00																		5.00					5.00							
H5528	011	0	1	04	01	H5528_011_0	13	3	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		95.00	190.00	190.00																						95.00	190.00	190.00																		95.00					95.00			95.00				
H5528	011	0	1	04	01	H5528_011_0	13	2	Preferred Brand	1	4	010001	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		35.00	70.00	70.00																						35.00	70.00	70.00																		35.00					35.00			35.00				
H5528	011	0	1	04	01	H5528_011_0	13	1	Preferred Generic	3	4	001000	1	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					5.00	10.00	10.00																						5.00	10.00	10.00																		5.00					5.00					1		
H5528	011	0	1	04	01	H5528_011_0	13	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					793.53	25	25	25																					25	25	25																	25				25			25			
H5528	018	0	1	04	01	H5528_018_0	13	4	Specialty Tier	1	2	010010		1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					835.27	25	25	25																					25	25	25																	25				25			25			
H5528	018	0	1	04	01	H5528_018_0	13	3	Non-Preferred Brand	1	2	100100		1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					61.47	30	30	30																					30	30	30																	30				30			30			
H5528	018	0	1	04	01	H5528_018_0	13	1	Preferred Generic	1	2	001000		2	011100000010111000000100	30	60	90							2	30	60	90							30		31					4.00	8.00	8.00																						4.00	8.00	8.00																		4.00					4.00							
H5528	018	0	1	04	01	H5528_018_0	13	2	Preferred Brand	1	2	010001		1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					49.24	25	25	25																					25	25	25																	25				25			25			
H5528	019	0	1	04	01	H5528_019_0	12	2	Preferred Brand	1	4	010001	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		35.00	70.00	70.00																						35.00	70.00	70.00																		35.00					35.00			35.00				
H5528	019	0	1	04	01	H5528_019_0	12	3	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		95.00	190.00	190.00																						95.00	190.00	190.00																		95.00					95.00			95.00				
H5528	019	0	1	04	01	H5528_019_0	12	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					1091.00	25	25	25																					25	25	25																	25				25			25			
H5528	019	0	1	04	01	H5528_019_0	12	1	Preferred Generic	3	4	001000	1	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					5.00	10.00	10.00																						5.00	10.00	10.00																		5.00					5.00					1		
H5528	019	0	1	04	01	H5528_019_0	12	1	Preferred Generic	1	4	001000	1	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					5.00	10.00	10.00																						5.00	10.00	10.00																		5.00					5.00							
H5528	020	0	1	04	01	H5528_020_0	13	1	Preferred Generic	1	4	001000	1	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					5.00	10.00	10.00																						5.00	10.00	10.00																		5.00					5.00							
H5528	020	0	1	04	01	H5528_020_0	13	2	Preferred Brand	1	4	010001	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		35.00	70.00	70.00																						35.00	70.00	70.00																		35.00					35.00			35.00				
H5528	020	0	1	04	01	H5528_020_0	13	3	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		95.00	190.00	190.00																						95.00	190.00	190.00																		95.00					95.00			95.00				
H5528	020	0	1	04	01	H5528_020_0	13	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					1091.00	25	25	25																					25	25	25																	25				25			25			
H5528	020	0	1	04	01	H5528_020_0	13	1	Preferred Generic	3	4	001000	1	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					5.00	10.00	10.00																						5.00	10.00	10.00																		5.00					5.00					1		
H5528	021	0	1	04	01	H5528_021_0	13	1	Preferred Generic	3	4	001000	1	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					5.00	10.00	10.00																						5.00	10.00	10.00																		5.00					5.00					1		
H5528	021	0	1	04	01	H5528_021_0	13	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					1091.00	25	25	25																					25	25	25																	25				25			25			
H5528	021	0	1	04	01	H5528_021_0	13	3	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		95.00	190.00	190.00																						95.00	190.00	190.00																		95.00					95.00			95.00				
H5528	021	0	1	04	01	H5528_021_0	13	2	Preferred Brand	1	4	010001	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		35.00	70.00	70.00																						35.00	70.00	70.00																		35.00					35.00			35.00				
H5528	021	0	1	04	01	H5528_021_0	13	1	Preferred Generic	1	4	001000	1	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					5.00	10.00	10.00																						5.00	10.00	10.00																		5.00					5.00							
H5529	001	0	1	04	01	H5529_001_0	12	5	Injectable Drugs	1	3	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					62.00	33	33	33																					33	33	33																	33				33			33			
H5529	001	0	1	04	01	H5529_001_0	12	4	Non-Preferred Brand	1	3	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H5529	001	0	1	04	01	H5529_001_0	12	3	Preferred Brand	1	3	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		44.00	88.00	132.00																						44.00	88.00	110.00																		44.00					44.00			44.00				
H5529	001	0	1	04	01	H5529_001_0	12	2	Non-Preferred Generic	1	3	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				13.00	26.00	39.00																						13.00	26.00	19.50																		13.00					13.00							
H5529	001	0	1	04	01	H5529_001_0	12	6	Specialty Tier	1	3	010010		1	110000000010100000000111	30										30									30		34	14	34	14					858.00	33																							33																			33				33			33			
H5529	001	0	1	04	01	H5529_001_0	12	1	Preferred Generic	1	3	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				4.00	8.00	12.00																						4.00	8.00	6.00																		4.00					4.00							
H5529	004	0	1	04	01	H5529_004_0	12	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				4.00	8.00	12.00																						4.00	8.00	6.00																		4.00					4.00							
H5529	004	0	1	04	01	H5529_004_0	12	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					975.00	33																							33																			33				33			33			
H5529	004	0	1	04	01	H5529_004_0	12	5	Injectable Drugs	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					68.00	33	33	33																					33	33	33																	33				33			33			
H5529	004	0	1	04	01	H5529_004_0	12	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H5529	004	0	1	04	01	H5529_004_0	12	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00					45.00			45.00				
H5529	004	0	1	04	01	H5529_004_0	12	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				9.00	18.00	27.00																						9.00	18.00	13.50																		9.00					9.00							
H5529	005	0	1	04	01	H5529_005_0	12	5	Injectable Drugs	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					68.00	33	33	33																					33	33	33																	33				33			33			
H5529	005	0	1	04	01	H5529_005_0	12	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H5529	005	0	1	04	01	H5529_005_0	12	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00					45.00			45.00				
H5529	005	0	1	04	01	H5529_005_0	12	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				9.00	18.00	27.00																						9.00	18.00	13.50																		9.00					9.00							
H5529	005	0	1	04	01	H5529_005_0	12	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				4.00	8.00	12.00																						4.00	8.00	6.00																		4.00					4.00							
H5529	005	0	1	04	01	H5529_005_0	12	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					975.00	33																							33																			33				33			33			
H5530	001	0	1	04	01	H5530_001_0	12	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					630.00	33																							33																			33				33			33			
H5530	001	0	1	04	01	H5530_001_0	12	5	Injectable Drugs	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					81.00	33	33	33																					33	33	33																	33				33			33			
H5530	001	0	1	04	01	H5530_001_0	12	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H5530	001	0	1	04	01	H5530_001_0	12	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00					45.00			45.00				
H5530	001	0	1	04	01	H5530_001_0	12	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				8.00	16.00	24.00																						8.00	16.00	12.00																		8.00					8.00							
H5530	001	0	1	04	01	H5530_001_0	12	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				4.00	8.00	12.00																						4.00	8.00	6.00																		4.00					4.00							
H5530	004	0	1	04	01	H5530_004_0	12	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				8.00	16.00	24.00																						8.00	16.00	12.00																		8.00					8.00							
H5530	004	0	1	04	01	H5530_004_0	12	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				4.00	8.00	12.00																						4.00	8.00	6.00																		4.00					4.00							
H5530	004	0	1	04	01	H5530_004_0	12	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00					45.00			45.00				
H5530	004	0	1	04	01	H5530_004_0	12	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H5530	004	0	1	04	01	H5530_004_0	12	5	Injectable Drugs	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					53.00	33	33	33																					33	33	33																	33				33			33			
H5530	004	0	1	04	01	H5530_004_0	12	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					1231.00	33																							33																			33				33			33			
H5532	001	0	1	04	01	H5532_001_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00							
H5532	001	0	1	04	01	H5532_001_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H5532	001	0	1	04	01	H5532_001_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H5532	001	0	1	04	01	H5532_001_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H5532	001	0	1	04	01	H5532_001_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					737.00	33		33																														33							33			33				33			33			
H5533	003	0	1	04	01	H5533_003_0	9	4	Specialty Tier	1	3	010010		1	110000000010100000000111	31										31									31		31	14	31	14					760.00	33																							33																			33				33			33			
H5533	003	0	1	04	01	H5533_003_0	9	5	Select Care Drugs	1	3	010000		2	010100000010001000000110	31		90							1			90							31		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5533	003	0	1	04	01	H5533_003_0	9	3	Non-Preferred Brand	1	3	100000		2	110100000010001000000001	31		90							1			90							31				31	14		95.00		285.00																								285.00																		95.00								95.00				
H5533	003	0	1	04	01	H5533_003_0	9	2	Preferred Brand	1	3	000001		2	110100000010001000000001	31		90							1			90							31				31	14		44.00		121.00																								110.00																		44.00								44.00				
H5533	003	0	1	04	01	H5533_003_0	9	1	Generic	1	3	010000		2	010100000010001000000110	31		90							1			90							31		31	14				9.00		18.00																								18.00																		9.00					9.00							
H5533	004	0	1	04	01	H5533_004_0	11	1	Generic	1	3	010000		2	010100000010001000000110	31		90							1			90							31		31	14				8.00		16.00																								16.00																		8.00					8.00							
H5533	004	0	1	04	01	H5533_004_0	11	2	Preferred Brand	1	3	000001		2	110100000010001000000001	31		90							1			90							31				31	14		44.00		121.00																								110.00																		44.00								44.00				
H5533	004	0	1	04	01	H5533_004_0	11	3	Non-Preferred Brand	1	3	100000		2	110100000010001000000001	31		90							1			90							31				31	14		95.00		285.00																								285.00																		95.00								95.00				
H5533	004	0	1	04	01	H5533_004_0	11	4	Specialty Tier	1	3	010010		1	110000000010100000000111	31										31									31		31	14	31	14					760.00	33																							33																			33				33			33			
H5533	004	0	1	04	01	H5533_004_0	11	5	Select Care Drugs	1	3	010000		2	010100000010001000000110	31		90							1			90							31		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5549	004	0	1	01	01	H5549_004_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					1.00		3.00																								2.50																		1.00					1.00							
H5549	004	0	1	01	01	H5549_004_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					4.00		12.00																								10.00																		4.00					4.00							
H5549	004	0	1	01	01	H5549_004_0	8	5	Specialty Tier	1	4	100000	1	1	110100000010001000000001	30		90							2			90							30				31	14					400.11	25		25																							25																	25							25			
H5549	004	0	1	01	01	H5549_004_0	8	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							2			90							30				31	14		90.00		270.00																								225.00																		90.00								90.00				
H5549	004	0	1	01	01	H5549_004_0	8	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		30.00		90.00																								75.00																		30.00								30.00				
H5575	006	0	1	01	01	H5575_006_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				5.00		10.00																								10.00																		5.00					5.00							
H5575	006	0	1	01	01	H5575_006_0	9	2	Preferred Brand	1	4	010001	1	2	110100000010001000000111	31		90							1			90							31		31	14	31	14		30.00		60.00																								60.00																		30.00					30.00			30.00				
H5575	006	0	1	01	01	H5575_006_0	9	3	Non-Preferred Brand	1	4	110000	1	2	110100000010001000000111	31		90							1			90							31		31	14	31	14		65.00		130.00																								130.00																		65.00					65.00			65.00				
H5575	006	0	1	01	01	H5575_006_0	9	4	Specialty Tier	1	4	010010	1	1	110100000010100000000111	31		90							1	31									31		31	14	31	14					366.46	33		33																					33																			33				33			33			
H5575	007	0	1	01	01	H5575_007_0	11	4	Specialty Tier	1	4	010010	1	1	110100000010100000000111	31		90							1	31									31		31	14	31	14					366.17	33		33																					33																			33				33			33			
H5575	007	0	1	01	01	H5575_007_0	11	3	Non-Preferred Brand	1	4	110000	1	2	110100000010001000000111	31		90							1			90							31		31	14	31	14		65.00		130.00																								130.00																		65.00					65.00			65.00				
H5575	007	0	1	01	01	H5575_007_0	11	2	Preferred Brand	1	4	010001	1	2	110100000010001000000111	31		90							1			90							31		31	14	31	14		30.00		60.00																								60.00																		30.00					30.00			30.00				
H5575	007	0	1	01	01	H5575_007_0	11	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				5.00		10.00																								10.00																		5.00					5.00							
H5576	006	0	1	02	01	H5576_006_0	15	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	31	60	90							1	31	60	90							31				31	14		85.00	170.00	255.00																						85.00	170.00	255.00																		85.00								85.00				
H5576	006	0	1	02	01	H5576_006_0	15	4	Specialty Tier	1	4	100000	1	1	110000000010100000000001	31										31									31				31	14					321.00	25																							25																			25							25			
H5576	006	0	1	02	01	H5576_006_0	15	1	Generic	1	4	010000	1	2	011100000010111000000110	31	60	90							1	31	60	90							31		31	14				5.00	10.00	15.00																						5.00	10.00	15.00																		5.00					5.00							
H5576	006	0	1	02	01	H5576_006_0	15	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	31	60	90							1	31	60	90							31				31	14		45.00	90.00	135.00																						45.00	90.00	135.00																		45.00								45.00				
H5576	006	0	1	02	01	H5576_006_0	15	1	Generic	3	4	010000	1	2	011100000010111000000110	31	60	90							1	31	60	90							31		31	14				5.00	10.00	15.00																						5.00	10.00	15.00																		5.00					5.00					1		
H5576	007	0	1	02	01	H5576_007_0	14	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	31	60	90							1	31	60	90							31				31	14		45.00	90.00	135.00																						45.00	90.00	135.00																		45.00								45.00				
H5576	007	0	1	02	01	H5576_007_0	14	1	Generic	1	4	010000	1	2	011100000010111000000110	31	60	90							1	31	60	90							31		31	14				5.00	10.00	15.00																						5.00	10.00	15.00																		5.00					5.00							
H5576	007	0	1	02	01	H5576_007_0	14	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	31	60	90							1	31	60	90							31				31	14		85.00	170.00	255.00																						85.00	170.00	255.00																		85.00								85.00				
H5576	007	0	1	02	01	H5576_007_0	14	4	Specialty Tier	1	4	100000	1	1	110000000010100000000001	31										31									31				31	14					365.00	25																							25																			25							25			
H5576	009	0	1	02	01	H5576_009_0	15	4	Specialty Tier	1	4	100000	1	1	110000000010100000000001	31										31									31				31	14					387.00	25																							25																			25							25			
H5576	009	0	1	02	01	H5576_009_0	15	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	31	60	90							1	31	60	90							31				31	14		85.00	170.00	255.00																						85.00	170.00	255.00																		85.00								85.00				
H5576	009	0	1	02	01	H5576_009_0	15	1	Generic	1	4	010000	1	2	011100000010111000000110	31	60	90							1	31	60	90							31		31	14				5.00	10.00	15.00																						5.00	10.00	15.00																		5.00					5.00							
H5576	009	0	1	02	01	H5576_009_0	15	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	31	60	90							1	31	60	90							31				31	14		45.00	90.00	135.00																						45.00	90.00	135.00																		45.00								45.00				
H5576	012	0	1	02	01	H5576_012_0	14	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	31	60	90							1	31	60	90							31				31	14		45.00	90.00	135.00																						45.00	90.00	135.00																		45.00								45.00				
H5576	012	0	1	02	01	H5576_012_0	14	1	Generic	1	4	010000	1	2	011100000010111000000110	31	60	90							1	31	60	90							31		31	14				5.00	10.00	15.00																						5.00	10.00	15.00																		5.00					5.00							
H5576	012	0	1	02	01	H5576_012_0	14	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	31	60	90							1	31	60	90							31				31	14		85.00	170.00	255.00																						85.00	170.00	255.00																		85.00								85.00				
H5576	012	0	1	02	01	H5576_012_0	14	4	Specialty Tier	1	4	100000	1	1	110000000010100000000001	31										31									31				31	14					352.00	33																							33																			33							33			
H5576	012	0	1	02	01	H5576_012_0	14	1	Generic	3	4	010000	1	2	011100000010111000000110	31	60	90							1	31	60	90							31		31	14				5.00	10.00	15.00																						5.00	10.00	15.00																		5.00					5.00					1		
H5577	005	0	1	01	01	H5577_005_0	7	4	Specialty Tier	1	4	110001	1	1	110000000010100000000101	30										30									30		31		31	1					613.24	25																							25																			25				25			25			
H5577	005	0	1	01	01	H5577_005_0	7	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							1	30		90							30				31	1		50.00		150.00																						50.00		100.00																		50.00								50.00				
H5577	005	0	1	01	01	H5577_005_0	7	1	Generic	3	4	010000	1	2	010100000010101000000100	30		90							1	30		90							30		31					5.00		15.00																						5.00		10.00																		5.00					5.00					1		
H5577	005	0	1	01	01	H5577_005_0	7	1	Generic	1	4	010000	1	2	010100000010101000000100	30		90							1	30		90							30		31					5.00		15.00																						5.00		10.00																		5.00					5.00							
H5577	005	0	1	01	01	H5577_005_0	7	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							1	30		90							30				31	1		25.00		75.00																						25.00		50.00																		25.00								25.00				
H5577	007	0	1	01	01	H5577_007_0	8	4	Specialty Tier	1	4	110001	1	1	110000000010100000000101	30										30									30		31		31	1					613.24	25																							25																			25				25			25			
H5577	007	0	1	01	01	H5577_007_0	8	1	Generic	3	4	010000	1	2	010100000010101000000100	30		90							1	30		90							30		31					3.00		9.00																						3.00		6.00																		3.00					3.00					1		
H5577	007	0	1	01	01	H5577_007_0	8	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							1	30		90							30				31	1		24.00		72.00																						24.00		48.00																		24.00								24.00				
H5577	007	0	1	01	01	H5577_007_0	8	1	Generic	1	4	010000	1	2	010100000010101000000100	30		90							1	30		90							30		31					3.00		9.00																						3.00		6.00																		3.00					3.00							
H5577	007	0	1	01	01	H5577_007_0	8	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							1	30		90							30				31	1		48.00		144.00																						48.00		96.00																		48.00								48.00				
H5577	008	0	1	02	01	H5577_008_0	7	1	Generic	1	4	010000	1	2	010100000010101000000100	30		90							1	30		90							30		31					4.00		12.00																						4.00		8.00																		4.00					4.00							
H5577	008	0	1	02	01	H5577_008_0	7	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							1	30		90							30				31	1		25.00		75.00																						25.00		50.00																		25.00								25.00				
H5577	008	0	1	02	01	H5577_008_0	7	1	Generic	3	4	010000	1	2	010100000010101000000100	30		90							1	30		90							30		31					4.00		12.00																						4.00		8.00																		4.00					4.00					1		
H5577	008	0	1	02	01	H5577_008_0	7	4	Specialty Tier	1	4	110001	1	1	110000000010100000000101	30										30									30		31		31	1					613.24	25																							25																			25				25			25			
H5577	008	0	1	02	01	H5577_008_0	7	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							1	30		90							30				31	1		50.00		150.00																						50.00		100.00																		50.00								50.00				
H5577	012	0	1	02	01	H5577_012_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							1	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00							
H5577	012	0	1	02	01	H5577_012_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							1	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00							
H5577	012	0	1	02	01	H5577_012_0	8	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							1	30		90							30				31	1		14.00		42.00																						14.00		28.00																		14.00								14.00				
H5577	012	0	1	02	01	H5577_012_0	8	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							1	30		90							30				31	1		28.00		84.00																						28.00		56.00																		28.00								28.00				
H5577	012	0	1	02	01	H5577_012_0	8	5	Specialty Tier	1	4	101101	1	1	110000000010100000000101	30										30									30		31		31	1					613.24	25																							25																			25				25			25			
H5577	012	0	1	02	01	H5577_012_0	8	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		90							1	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00					1		
H5577	012	0	1	02	01	H5577_012_0	8	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000100	30		90							1	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00					1		
H5591	001	0	1	02	01	H5591_001_0	6	1	Preferred Generic	1	4	001001	1	2	100011111110111000000111				30	60	90	30	60	90	1	30	60	90							30		31	14	31	14										0.00	0.00	0.00						4.00	8.00	12.00						4.00	8.00	10.00																		4.00					4.00			4.00				
H5591	001	0	1	02	01	H5591_001_0	6	2	Non-Preferred Generic	1	4	000101	1	2	100011111110111000000111				30	60	90	30	60	90	1	30	60	90							30		31	14	31	14										6.00	12.00	18.00						10.00	20.00	30.00						10.00	20.00	25.00																		10.00					10.00			10.00				
H5591	001	0	1	02	01	H5591_001_0	6	3	Preferred Brand	1	4	000101	1	2	100011111110111000000111				30	60	90	30	60	90	1	30	60	90							30		31	14	31	14										40.00	80.00	120.00						40.00	80.00	120.00						40.00	80.00	100.00																		40.00					40.00			40.00				
H5591	001	0	1	02	01	H5591_001_0	6	5	Specialty Tier	1	4	010010	1	1	100011111110111000000111				30	60	90	30	60	90	1	30	60	90							30		31	14	31	14													600.00	33	33	33					600.00	33	33	33					33	33	33																	33				33			33			
H5591	001	0	1	02	01	H5591_001_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100011111110111000000111				30	60	90	30	60	90	1	30	60	90							30		31	14	31	14										80.00	160.00	240.00						80.00	160.00	240.00						80.00	160.00	200.00																		80.00					80.00			80.00				
H5591	004	0	1	02	01	H5591_004_0	6	2	Non-Preferred Generic	1	4	000101	1	2	100011111110111000000111				30	60	90	30	60	90	1	30	60	90							30		31	14	31	14										6.00	12.00	18.00						10.00	20.00	30.00						10.00	20.00	25.00																		10.00					10.00			10.00				
H5591	004	0	1	02	01	H5591_004_0	6	1	Preferred Generic	1	4	001001	1	2	100011111110111000000111				30	60	90	30	60	90	1	30	60	90							30		31	14	31	14										0.00	0.00	0.00						4.00	8.00	12.00						4.00	8.00	10.00																		4.00					4.00			4.00				
H5591	004	0	1	02	01	H5591_004_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100011111110111000000111				30	60	90	30	60	90	1	30	60	90							30		31	14	31	14										80.00	160.00	240.00						80.00	160.00	240.00						80.00	160.00	200.00																		80.00					80.00			80.00				
H5591	004	0	1	02	01	H5591_004_0	6	3	Preferred Brand	1	4	000101	1	2	100011111110111000000111				30	60	90	30	60	90	1	30	60	90							30		31	14	31	14										40.00	80.00	120.00						40.00	80.00	120.00						40.00	80.00	100.00																		40.00					40.00			40.00				
H5591	004	0	1	02	01	H5591_004_0	6	5	Specialty Tier	1	4	010010	1	1	100011111110111000000111				30	60	90	30	60	90	1	30	60	90							30		31	14	31	14													600.00	33	33	33					600.00	33	33	33					33	33	33																	33				33			33			
H5591	005	0	1	02	01	H5591_005_0	6	2	Non-Preferred Generic	1	4	000101	1	2	100011111110111000000111				30	60	90	30	60	90	1	30	60	90							30		31	14	31	14										6.00	12.00	18.00						10.00	20.00	30.00						10.00	20.00	25.00																		10.00					10.00			10.00				
H5591	005	0	1	02	01	H5591_005_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100011111110111000000111				30	60	90	30	60	90	1	30	60	90							30		31	14	31	14										80.00	160.00	240.00						80.00	160.00	240.00						80.00	160.00	200.00																		80.00					80.00			80.00				
H5591	005	0	1	02	01	H5591_005_0	6	1	Preferred Generic	1	4	001001	1	2	100011111110111000000111				30	60	90	30	60	90	1	30	60	90							30		31	14	31	14										0.00	0.00	0.00						4.00	8.00	12.00						4.00	8.00	10.00																		4.00					4.00			4.00				
H5591	005	0	1	02	01	H5591_005_0	6	3	Preferred Brand	1	4	000101	1	2	100011111110111000000111				30	60	90	30	60	90	1	30	60	90							30		31	14	31	14										40.00	80.00	120.00						40.00	80.00	120.00						40.00	80.00	100.00																		40.00					40.00			40.00				
H5591	005	0	1	02	01	H5591_005_0	6	5	Specialty Tier	1	4	010010	1	1	100011111110111000000111				30	60	90	30	60	90	1	30	60	90							30		31	14	31	14													600.00	33	33	33					600.00	33	33	33					33	33	33																	33				33			33			
H5594	001	0	1	02	01	H5594_001_0	5	1	Preferred Generic	1	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00				
H5594	001	0	1	02	01	H5594_001_0	5	1	Preferred Generic	3	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00		1		
H5594	001	0	1	02	01	H5594_001_0	5	4	Specialty Tier	1	4	100100	1	1	110100000010101000000111	30		90							1	30		90							30		31	14	31	14					792.92	33		33																					33		33																	33				33			33			
H5594	001	0	1	02	01	H5594_001_0	5	3	Non-Preferred Brand	1	4	100100	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		69.00		207.00																						69.00		138.00																		69.00					69.00			69.00				
H5594	001	0	1	02	01	H5594_001_0	5	2	Preferred Brand	1	4	000101	1	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		20.00		60.00																						20.00		40.00																		20.00					20.00			20.00				
H5594	002	0	1	02	01	H5594_002_0	6	3	Non-Preferred Brand	1	4	100100	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		60.00		180.00																						60.00		120.00																		60.00					60.00			60.00				
H5594	002	0	1	02	01	H5594_002_0	6	4	Specialty Tier	1	4	100100	1	1	110100000010101000000111	30		90							1	30		90							30		31	14	31	14					604.33	33		33																					33		33																	33				33			33			
H5594	002	0	1	02	01	H5594_002_0	6	2	Preferred Brand	1	4	000101	1	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		5.00		15.00																						5.00		10.00																		5.00					5.00			5.00				
H5594	002	0	1	02	01	H5594_002_0	6	1	Preferred Generic	1	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00				
H5594	002	0	1	02	01	H5594_002_0	6	1	Preferred Generic	3	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00		1		
H5594	006	0	1	02	01	H5594_006_0	8	2	Preferred Brand	1	4	000101	1	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		45.00		135.00																						45.00		90.00																		45.00					45.00			45.00				
H5594	006	0	1	02	01	H5594_006_0	8	3	Non-Preferred Brand	1	4	100100	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		75.00		225.00																						75.00		150.00																		75.00					75.00			75.00				
H5594	006	0	1	02	01	H5594_006_0	8	4	Specialty Tier	1	4	100100	1	1	110100000010101000000111	30		90							1	30		90							30		31	14	31	14					469.44	33		33																					33		33																	33				33			33			
H5594	006	0	1	02	01	H5594_006_0	8	1	Preferred Generic	1	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00				
H5594	018	0	1	02	01	H5594_018_0	7	3	Non-Preferred Brand	1	4	100100	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		69.00		207.00																						69.00		138.00																		69.00					69.00			69.00				
H5594	018	0	1	02	01	H5594_018_0	7	4	Specialty Tier	1	4	100100	1	1	110100000010101000000111	30		90							1	30		90							30		31	14	31	14					679.05	33		33																					33		33																	33				33			33			
H5594	018	0	1	02	01	H5594_018_0	7	1	Preferred Generic	1	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00				
H5594	018	0	1	02	01	H5594_018_0	7	2	Preferred Brand	1	4	000101	1	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		39.00		117.00																						39.00		78.00																		39.00					39.00			39.00				
H5594	019	0	1	02	01	H5594_019_0	5	1	Preferred Generic	1	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00				
H5594	019	0	1	02	01	H5594_019_0	5	1	Preferred Generic	3	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00		1		
H5594	019	0	1	02	01	H5594_019_0	5	2	Preferred Brand	1	4	000101	1	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		20.00		60.00																						20.00		40.00																		20.00					20.00			20.00				
H5594	019	0	1	02	01	H5594_019_0	5	4	Specialty Tier	1	4	100100	1	1	110100000010101000000111	30		90							1	30		90							30		31	14	31	14					780.64	33		33																					33		33																	33				33			33			
H5594	019	0	1	02	01	H5594_019_0	5	3	Non-Preferred Brand	1	4	100100	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		65.00		195.00																						65.00		130.00																		65.00					65.00			65.00				
H5594	022	0	1	02	01	H5594_022_0	7	4	Specialty Tier	1	4	100100	1	1	110100000010101000000111	30		90							1	30		90							30		31	14	31	14					793.01	33		33																					33		33																	33				33			33			
H5594	022	0	1	02	01	H5594_022_0	7	3	Non-Preferred Brand	1	4	100100	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		69.00		207.00																						69.00		138.00																		69.00					69.00			69.00				
H5594	022	0	1	02	01	H5594_022_0	7	1	Preferred Generic	1	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00				
H5594	022	0	1	02	01	H5594_022_0	7	2	Preferred Brand	1	4	000101	1	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		35.00		105.00																						35.00		70.00																		35.00					35.00			35.00				
H5594	023	0	1	02	01	H5594_023_0	6	2	Preferred Brand	1	4	000101	1	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		10.00		30.00																						10.00		20.00																		10.00					10.00			10.00				
H5594	023	0	1	02	01	H5594_023_0	6	3	Non-Preferred Brand	1	4	100100	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		65.00		195.00																						65.00		130.00																		65.00					65.00			65.00				
H5594	023	0	1	02	01	H5594_023_0	6	4	Specialty Tier	1	4	100100	1	1	110100000010101000000111	30		90							1	30		90							30		31	14	31	14					602.62	33		33																					33		33																	33				33			33			
H5594	023	0	1	02	01	H5594_023_0	6	1	Preferred Generic	1	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00				
H5594	023	0	1	02	01	H5594_023_0	6	1	Preferred Generic	3	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00		1		
H5594	026	0	1	02	01	H5594_026_0	7	3	Non-Preferred Brand	1	4	100100	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		69.00		207.00																						69.00		138.00																		69.00					69.00			69.00				
H5594	026	0	1	02	01	H5594_026_0	7	2	Preferred Brand	1	4	000101	1	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		35.00		105.00																						35.00		70.00																		35.00					35.00			35.00				
H5594	026	0	1	02	01	H5594_026_0	7	1	Preferred Generic	1	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00				
H5594	026	0	1	02	01	H5594_026_0	7	4	Specialty Tier	1	4	100100	1	1	110100000010101000000111	30		90							1	30		90							30		31	14	31	14					793.06	33		33																					33		33																	33				33			33			
H5594	027	0	1	02	01	H5594_027_0	6	1	Preferred Generic	3	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00		1		
H5594	027	0	1	02	01	H5594_027_0	6	1	Preferred Generic	1	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00				
H5594	027	0	1	02	01	H5594_027_0	6	2	Preferred Brand	1	4	000101	1	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		10.00		30.00																						10.00		20.00																		10.00					10.00			10.00				
H5594	027	0	1	02	01	H5594_027_0	6	3	Non-Preferred Brand	1	4	100100	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		65.00		195.00																						65.00		130.00																		65.00					65.00			65.00				
H5594	027	0	1	02	01	H5594_027_0	6	4	Specialty Tier	1	4	100100	1	1	110100000010101000000111	30		90							1	30		90							30		31	14	31	14					601.00	33		33																					33		33																	33				33			33			
H5594	028	0	1	02	01	H5594_028_0	7	4	Specialty Tier	1	4	100100	1	1	110100000010101000000111	30		90							1	30		90							30		31	14	31	14					855.34	33		33																					33		33																	33				33			33			
H5594	028	0	1	02	01	H5594_028_0	7	3	Non-Preferred Brand	1	4	100100	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		50.00		150.00																						50.00		100.00																		50.00					50.00			50.00				
H5594	028	0	1	02	01	H5594_028_0	7	2	Preferred Brand	1	4	000101	1	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		20.00		60.00																						20.00		40.00																		20.00					20.00			20.00				
H5594	028	0	1	02	01	H5594_028_0	7	1	Preferred Generic	1	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00				
H5594	028	0	1	02	01	H5594_028_0	7	1	Preferred Generic	3	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00		1		
H5594	029	0	1	02	01	H5594_029_0	7	4	Specialty Tier	1	4	100100	1	1	110100000010101000000111	30		90							1	30		90							30		31	14	31	14					435.29	33		33																					33		33																	33				33			33			
H5594	029	0	1	02	01	H5594_029_0	7	3	Non-Preferred Brand	1	4	100100	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		50.00		150.00																						50.00		100.00																		50.00					50.00			50.00				
H5594	029	0	1	02	01	H5594_029_0	7	2	Preferred Brand	1	4	000101	1	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		20.00		60.00																						20.00		40.00																		20.00					20.00			20.00				
H5594	029	0	1	02	01	H5594_029_0	7	1	Preferred Generic	1	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00				
H5594	029	0	1	02	01	H5594_029_0	7	1	Preferred Generic	3	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00		1		
H5594	030	0	1	02	01	H5594_030_0	7	1	Preferred Generic	1	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00				
H5594	030	0	1	02	01	H5594_030_0	7	2	Preferred Brand	1	4	000101	1	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		20.00		60.00																						20.00		40.00																		20.00					20.00			20.00				
H5594	030	0	1	02	01	H5594_030_0	7	3	Non-Preferred Brand	1	4	100100	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		50.00		150.00																						50.00		100.00																		50.00					50.00			50.00				
H5594	030	0	1	02	01	H5594_030_0	7	4	Specialty Tier	1	4	100100	1	1	110100000010101000000111	30		90							1	30		90							30		31	14	31	14					873.87	33		33																					33		33																	33				33			33			
H5594	030	0	1	02	01	H5594_030_0	7	1	Preferred Generic	3	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00		1		
H5594	031	0	1	02	01	H5594_031_0	7	1	Preferred Generic	1	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00				
H5594	031	0	1	02	01	H5594_031_0	7	2	Preferred Brand	1	4	000101	1	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		20.00		60.00																						20.00		40.00																		20.00					20.00			20.00				
H5594	031	0	1	02	01	H5594_031_0	7	3	Non-Preferred Brand	1	4	100100	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		50.00		150.00																						50.00		100.00																		50.00					50.00			50.00				
H5594	031	0	1	02	01	H5594_031_0	7	4	Specialty Tier	1	4	100100	1	1	110100000010101000000111	30		90							1	30		90							30		31	14	31	14					438.73	33		33																					33		33																	33				33			33			
H5594	031	0	1	02	01	H5594_031_0	7	1	Preferred Generic	3	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00		1		
H5608	002	0	1	01	01	H5608_002_0	8	4	Non-Preferred Brand	1	2	100000		1	110100000001001000000001	31		90							2			90								10			31	10					51.27	45		45																							45																		45						45			
H5608	002	0	1	01	01	H5608_002_0	8	3	Preferred Brand	1	2	000001		1	110100000001001000000001	31		90							2			90								10			31	10					34.17	25		25																							25																		25						25			
H5608	002	0	1	01	01	H5608_002_0	8	2	Non-Preferred Generic	1	2	000100		2	010100000001001000000100	31		90							1			90								10	31					10.00		30.00																								20.00																			10.00				10.00							
H5608	002	0	1	01	01	H5608_002_0	8	1	Preferred Generic	1	2	001000		2	010100000001001000000100	31		90							1			90								10	31					4.00		12.00																								8.00																			4.00				4.00							
H5609	001	0	1	01	01	H5609_001_0	8	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				5.00		15.00																								15.00																		5.00				.16	5.00					1		
H5609	001	0	1	01	01	H5609_001_0	8	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		45.00		135.00																								135.00																		45.00							1.45	45.00				
H5609	001	0	1	01	01	H5609_001_0	8	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		90.00		270.00																								270.00																		90.00							2.90	90.00				
H5609	001	0	1	01	01	H5609_001_0	8	5	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							1			90							30		31	14	31	14					33.00	33		33																							33																	33				33			33			
H5609	001	0	1	01	01	H5609_001_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				15.00		45.00																								45.00																		15.00				.48	15.00							
H5609	001	0	1	01	01	H5609_001_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				5.00		15.00																								15.00																		5.00				.16	5.00							
H5609	004	0	1	01	01	H5609_004_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				15.00		45.00																								45.00																		15.00				.48	15.00							
H5609	004	0	1	01	01	H5609_004_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		45.00		135.00																								135.00																		45.00							1.45	45.00				
H5609	004	0	1	01	01	H5609_004_0	6	5	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							1			90							30		31	14	31	14					33.00	33		33																							33																	33				33			33			
H5609	004	0	1	01	01	H5609_004_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		90.00		270.00																								270.00																		90.00							2.90	90.00				
H5609	004	0	1	01	01	H5609_004_0	6	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				5.00		15.00																								15.00																		5.00				.16	5.00					1		
H5609	004	0	1	01	01	H5609_004_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				5.00		15.00																								15.00																		5.00				.16	5.00							
H5609	005	0	1	01	01	H5609_005_0	7	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				5.00		15.00																								15.00																		5.00				.16	5.00					1		
H5609	005	0	1	01	01	H5609_005_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							1			90							30		31	14	31	14					33.00	33		33																							33																	33				33			33			
H5609	005	0	1	01	01	H5609_005_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		90.00		270.00																								270.00																		90.00							2.90	90.00				
H5609	005	0	1	01	01	H5609_005_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				15.00		45.00																								45.00																		15.00				.48	15.00							
H5609	005	0	1	01	01	H5609_005_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				5.00		15.00																								15.00																		5.00				.16	5.00							
H5609	005	0	1	01	01	H5609_005_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		45.00		135.00																								135.00																		45.00							1.45	45.00				
H5619	001	0	1	01	01	H5619_001_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H5619	001	0	1	01	01	H5619_001_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					2906.00	33																														33							33					33				33			33	2	3	
H5619	001	0	1	01	01	H5619_001_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H5619	001	0	1	01	01	H5619_001_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H5619	001	0	1	01	01	H5619_001_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H5619	001	0	1	01	01	H5619_001_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H5619	001	0	1	01	01	H5619_001_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					774.00	33																														33							33					33				33			33			
H5619	001	0	1	01	01	H5619_001_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H5619	001	0	1	01	01	H5619_001_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H5619	001	0	1	01	01	H5619_001_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H5619	003	0	1	01	01	H5619_003_0	12	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H5619	003	0	1	01	01	H5619_003_0	12	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H5619	003	0	1	01	01	H5619_003_0	12	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H5619	003	0	1	01	01	H5619_003_0	12	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					390.00	25																														25							25					25				25			25			
H5619	007	0	1	01	01	H5619_007_0	10	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H5619	007	0	1	01	01	H5619_007_0	10	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H5619	007	0	1	01	01	H5619_007_0	10	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H5619	007	0	1	01	01	H5619_007_0	10	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H5619	007	0	1	01	01	H5619_007_0	10	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H5619	007	0	1	01	01	H5619_007_0	10	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H5619	007	0	1	01	01	H5619_007_0	10	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					2765.00	33																														33							33					33				33			33	2	3	
H5619	007	0	1	01	01	H5619_007_0	10	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H5619	007	0	1	01	01	H5619_007_0	10	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					797.00	33																														33							33					33				33			33			
H5619	007	0	1	01	01	H5619_007_0	10	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H5619	009	0	1	01	01	H5619_009_0	11	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					247.00	25																														25							25					25				25			25			
H5619	009	0	1	01	01	H5619_009_0	11	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H5619	009	0	1	01	01	H5619_009_0	11	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H5619	009	0	1	01	01	H5619_009_0	11	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H5628	001	0	1	01	01	H5628_001_0	7	4	Specialty Tier	1	4	010010	1	1	110000000010100000000111	31										31									31		31	14	31	14					455.71	25																							25																			25				25			25			
H5628	001	0	1	01	01	H5628_001_0	7	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	31	60	90							1	31	60	90							31				31	14		95.00	190.00	285.00																						95.00	190.00	285.00																		95.00								95.00				
H5628	001	0	1	01	01	H5628_001_0	7	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	31	60	90							1	31	60	90							31				31	14		45.00	90.00	135.00																						45.00	90.00	135.00																		45.00								45.00				
H5628	001	0	1	01	01	H5628_001_0	7	1	Generic	1	4	010000	1	2	011100000010111000000110	31	60	90							1	31	60	90							31		31	14				0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00							
H5649	001	0	1	01	01	H5649_001_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H5649	001	0	1	01	01	H5649_001_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								10.00																		5.00					5.00							
H5649	001	0	1	01	01	H5649_001_0	10	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		25.00		75.00																								50.00																		25.00								25.00				
H5649	001	0	1	01	01	H5649_001_0	10	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		50.00		150.00																								100.00																		50.00								50.00				
H5649	001	0	1	01	01	H5649_001_0	10	5	Specialty Tier	1	4	010010	1	1	110100000010001000000101	30		90							2			90							30		31		31	14					118.17	33		33																							33																	33				33			33			
H5649	001	0	1	01	01	H5649_001_0	10	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00					1		
H5649	001	0	1	01	01	H5649_001_0	10	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		15.00																								10.00																		5.00					5.00					1		
H5649	002	0	1	01	01	H5649_002_0	8	4	Non-Preferred Brand	1	4	100000	3	1	110100000010001000000001	30		90							1			90							30				31	14					48.02	25		25																							25																	25							25			
H5649	002	0	1	01	01	H5649_002_0	8	5	Specialty Tier	1	4	010010	1	1	110100000010001000000101	30		90							2			90							30		31		31	14					70.86	25		25																							25																	25				25			25			
H5649	002	0	1	01	01	H5649_002_0	8	3	Preferred Brand	1	4	000001	1	1	110100000010001000000001	30		90							1			90							30				31	14					25.04	25		25																							25																	25							25			
H5649	002	0	1	01	01	H5649_002_0	8	2	Non-Preferred Generic	1	4	000100	3	1	010100000010001000000100	30		90							1			90							30		31								4.97	25		25																							25																	25				25						
H5649	002	0	1	01	01	H5649_002_0	8	1	Preferred Generic	1	4	001000	1	1	010100000010001000000100	30		90							1			90							30		31								0.00	25		25																							25																	25				25						
H5649	004	0	1	01	01	H5649_004_0	8	5	Specialty Tier	1	4	010010	1	1	110100000010001000000101	30		90							2			90							30		31		31	14					70.86	25		25																							25																	25				25			25			
H5649	004	0	1	01	01	H5649_004_0	8	4	Non-Preferred Brand	1	4	100000	3	1	110100000010001000000001	30		90							1			90							30				31	14					48.02	25		25																							25																	25							25			
H5649	004	0	1	01	01	H5649_004_0	8	3	Preferred Brand	1	4	000001	1	1	110100000010001000000001	30		90							1			90							30				31	14					25.04	25		25																							25																	25							25			
H5649	004	0	1	01	01	H5649_004_0	8	2	Non-Preferred Generic	1	4	000100	3	1	010100000010001000000100	30		90							1			90							30		31								4.97	25		25																							25																	25				25						
H5649	004	0	1	01	01	H5649_004_0	8	1	Preferred Generic	1	4	001000	1	1	010100000010001000000100	30		90							1			90							30		31								0.00	25		25																							25																	25				25						
H5652	001	0	1	02	01	H5652_001_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					4.00		12.00																															8.00							12.00				4.00					4.00							
H5652	001	0	1	02	01	H5652_001_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					7.00		21.00																															14.00							21.00				7.00					7.00							
H5652	001	0	1	02	01	H5652_001_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					302.00	33		33																														33							33			33				33			33			
H5652	001	0	1	02	01	H5652_001_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		40.00		120.00																															110.00							120.00				40.00					40.00			40.00				
H5652	001	0	1	02	01	H5652_001_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		80.00		240.00																															230.00							240.00				80.00					80.00			80.00				
H5652	003	0	1	02	01	H5652_003_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		80.00		240.00																															230.00							240.00				80.00					80.00			80.00				
H5652	003	0	1	02	01	H5652_003_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		40.00		120.00																															110.00							120.00				40.00					40.00			40.00				
H5652	003	0	1	02	01	H5652_003_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00							
H5652	003	0	1	02	01	H5652_003_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					4.00		12.00																															8.00							12.00				4.00					4.00							
H5652	003	0	1	02	01	H5652_003_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					191.00	33		33																														33							33			33				33			33			
H5652	004	0	1	02	01	H5652_004_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00							
H5652	004	0	1	02	01	H5652_004_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					4.00		12.00																															8.00							12.00				4.00					4.00							
H5652	004	0	1	02	01	H5652_004_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		40.00		120.00																															110.00							120.00				40.00					40.00			40.00				
H5652	004	0	1	02	01	H5652_004_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		80.00		240.00																															230.00							240.00				80.00					80.00			80.00				
H5652	004	0	1	02	01	H5652_004_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					366.00	33		33																														33							33			33				33			33			
H5652	006	0	1	02	01	H5652_006_0	7	2	Non-Preferred Generic	1	3	000100		2	010100000010000001001100	31		90							1						90			90	31		31					9.00		27.00																															18.00							27.00				9.00					9.00							
H5652	006	0	1	02	01	H5652_006_0	7	3	Preferred Brand	1	3	010001		2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H5652	006	0	1	02	01	H5652_006_0	7	1	Preferred Generic	1	3	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					5.00		15.00																															10.00							15.00				5.00					5.00							
H5652	006	0	1	02	01	H5652_006_0	7	5	Specialty Tier	1	3	010010		1	110100000010000001001101	31		90							1						90			90	31		31		31	14					302.00	33		33																														33							33			33				33			33			
H5652	006	0	1	02	01	H5652_006_0	7	4	Non-Preferred Brand	1	3	100100		2	110100000010000001001101	31		90							1						90			90	31		31		31	14		85.00		255.00																															245.00							255.00				85.00					85.00			85.00				
H5656	001	0	1	01	01	H5656_001_0	5	3	Preferred Brand	3	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		40.00		100.00																													40.00		80.00					40.00		100.00				40.00								40.00		2		
H5656	001	0	1	01	01	H5656_001_0	5	2	Non-Preferred Generic	3	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		7.00		17.50																													7.00		14.00					7.00		17.50				7.00					7.00			7.00		1		
H5656	001	0	1	01	01	H5656_001_0	5	1	Preferred Generic	3	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					2.00		5.00																													2.00		4.00					2.00		5.00				2.00					2.00					1		
H5656	001	0	1	01	01	H5656_001_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					500.00	33																														33							33					33				33			33			
H5656	001	0	1	01	01	H5656_001_0	5	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		80.00		200.00																													80.00		160.00					80.00		200.00				80.00								80.00				
H5656	001	0	1	01	01	H5656_001_0	5	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		40.00		100.00																													40.00		80.00					40.00		100.00				40.00								40.00				
H5656	001	0	1	01	01	H5656_001_0	5	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					2.00		5.00																													2.00		4.00					2.00		5.00				2.00					2.00							
H5656	001	0	1	01	01	H5656_001_0	5	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		7.00		17.50																													7.00		14.00					7.00		17.50				7.00					7.00			7.00				
H5656	014	0	1	01	01	H5656_014_0	8	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		80.00		200.00																													80.00		160.00					80.00		200.00				80.00								80.00				
H5656	014	0	1	01	01	H5656_014_0	8	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		40.00		100.00																													40.00		80.00					40.00		100.00				40.00								40.00				
H5656	014	0	1	01	01	H5656_014_0	8	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		7.00		17.50																													7.00		14.00					7.00		17.50				7.00					7.00			7.00				
H5656	014	0	1	01	01	H5656_014_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					2.00		5.00																													2.00		4.00					2.00		5.00				2.00					2.00							
H5656	014	0	1	01	01	H5656_014_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					500.00	33																														33							33					33				33			33			
H5656	015	0	1	01	01	H5656_015_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					2.00		5.00																													2.00		4.00					2.00		5.00				2.00					2.00							
H5656	015	0	1	01	01	H5656_015_0	8	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		7.00		17.50																													7.00		14.00					7.00		17.50				7.00					7.00			7.00				
H5656	015	0	1	01	01	H5656_015_0	8	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		40.00		100.00																													40.00		80.00					40.00		100.00				40.00								40.00				
H5656	015	0	1	01	01	H5656_015_0	8	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		80.00		200.00																													80.00		160.00					80.00		200.00				80.00								80.00				
H5656	015	0	1	01	01	H5656_015_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					500.00	33																														33							33					33				33			33			
H5656	015	0	1	01	01	H5656_015_0	8	1	Preferred Generic	3	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					2.00		5.00																													2.00		4.00					2.00		5.00				2.00					2.00					1		
H5656	015	0	1	01	01	H5656_015_0	8	2	Non-Preferred Generic	3	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		7.00		17.50																													7.00		14.00					7.00		17.50				7.00					7.00			7.00		1		
H5656	015	0	1	01	01	H5656_015_0	8	3	Preferred Brand	3	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		40.00		100.00																													40.00		80.00					40.00		100.00				40.00								40.00		2		
H5679	003	0	1	01	01	H5679_003_0	10	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				4.00	8.00	12.00																						4.00	8.00	6.00																		4.00					4.00							
H5679	003	0	1	01	01	H5679_003_0	10	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				10.00	20.00	30.00																						10.00	20.00	15.00																		10.00					10.00							
H5679	003	0	1	01	01	H5679_003_0	10	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					577.00	33																							33																			33				33			33			
H5679	003	0	1	01	01	H5679_003_0	10	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H5679	003	0	1	01	01	H5679_003_0	10	5	Injectable Drugs	1	4	010010	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H5679	003	0	1	01	01	H5679_003_0	10	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00					45.00			45.00				
H5685	001	0	1	01	01	H5685_001_0	4	2	Brand	1	4	000010	1	2	110000000001000000000001	30																				29			31	14	0.00	0.00																																													0.00						0.00	0.00				
H5685	001	0	1	01	01	H5685_001_0	4	1	Generic	1	4	010000	1	2	010000000001000000000100	30																				29	31				0.00	0.00																																													0.00			0.00	0.00							
H5696	002	0	1	01	01	H5696_002_0	10	1	Preferred Generic	1	4	001010	1	2	110100000010001000000101	30		90							1			90							30		31		31	14		2.00		4.00																								2.00																		2.00					2.00			2.00				
H5696	002	0	1	01	01	H5696_002_0	10	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		25.00		75.00																								50.00																		25.00								25.00				
H5696	002	0	1	01	01	H5696_002_0	10	3	Non-Preferred Brand	1	4	110000	3	2	110100000010001000000101	30		90							1			90							30		31		31	14		95.00		285.00																								285.00																		95.00					95.00			95.00				
H5696	002	0	1	01	01	H5696_002_0	10	4	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					443.56	33																							33																			33				33			33			
H5696	004	0	1	01	01	H5696_004_0	13	4	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					522.48	33																							33																			33				33			33			
H5696	004	0	1	01	01	H5696_004_0	13	3	Non-Preferred Brand	1	4	110000	3	2	110100000010001000000101	30		90							1			90							30		31		31	14		95.00		285.00																								285.00																		95.00					95.00			95.00				
H5696	004	0	1	01	01	H5696_004_0	13	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		85.00																								70.00																		35.00								35.00				
H5696	004	0	1	01	01	H5696_004_0	13	1	Preferred Generic	1	4	001010	1	2	110100000010001000000101	30		90							1			90							30		31		31	14		0.00		0.00																								0.00																		0.00					0.00			0.00				
H5696	021	0	1	01	01	H5696_021_0	16	4	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					380.82	25																							25																			25				25			25			
H5696	021	0	1	01	01	H5696_021_0	16	3	Non-Preferred Brand	1	4	110000	3	2	110100000010001000000101	30		90							1			90							30		31		31	14		0.00		0.00																								0.00																		0.00					0.00			0.00				
H5696	021	0	1	01	01	H5696_021_0	16	1	Preferred Generic	1	4	001010	1	2	110100000010001000000101	30		90							1			90							30		31		31	14		0.00		0.00																								0.00																		0.00					0.00			0.00				
H5696	021	0	1	01	01	H5696_021_0	16	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		0.00		0.00																								0.00																		0.00								0.00				
H5696	023	0	1	01	01	H5696_023_0	13	1	Preferred Generic	3	4	001010	1	2	110100000010001000000101	30		90							1			90							30		31		31	14		0.00		0.00																								0.00																		0.00					0.00			0.00		1		
H5696	023	0	1	01	01	H5696_023_0	13	3	Non-Preferred Brand	1	4	110000	3	2	110100000010001000000101	30		90							1			90							30		31		31	14		80.00		240.00																								240.00																		80.00					80.00			80.00				
H5696	023	0	1	01	01	H5696_023_0	13	4	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					966.02	33																							33																			33				33			33			
H5696	023	0	1	01	01	H5696_023_0	13	1	Preferred Generic	1	4	001010	1	2	110100000010001000000101	30		90							1			90							30		31		31	14		0.00		0.00																								0.00																		0.00					0.00			0.00				
H5696	023	0	1	01	01	H5696_023_0	13	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		30.00		75.00																								60.00																		30.00								30.00				
H5696	024	0	1	01	01	H5696_024_0	13	4	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					542.59	33																							33																			33				33			33			
H5696	024	0	1	01	01	H5696_024_0	13	1	Preferred Generic	1	4	001010	1	2	110100000010001000000101	30		90							1			90							30		31		31	14		0.00		0.00																								0.00																		0.00					0.00			0.00				
H5696	024	0	1	01	01	H5696_024_0	13	3	Non-Preferred Brand	1	4	110000	3	2	110100000010001000000101	30		90							1			90							30		31		31	14		95.00		285.00																								285.00																		95.00					95.00			95.00				
H5696	024	0	1	01	01	H5696_024_0	13	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								70.00																		35.00								35.00				
H5696	028	0	1	01	01	H5696_028_0	13	1	Preferred Generic	1	4	001010	1	2	110100000010001000000101	30		90							1			90							30		31		31	14		0.00		0.00																								0.00																		0.00					0.00			0.00				
H5696	028	0	1	01	01	H5696_028_0	13	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		15.00		35.00																								25.00																		15.00								15.00				
H5696	028	0	1	01	01	H5696_028_0	13	3	Non-Preferred Brand	1	4	110000	3	2	110100000010001000000101	30		90							1			90							30		31		31	14		90.00		270.00																								270.00																		90.00					90.00			90.00				
H5696	028	0	1	01	01	H5696_028_0	13	4	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					354.11	33																							33																			33				33			33			
H5696	030	0	1	01	01	H5696_030_0	13	3	Non-Preferred Brand	1	4	110000	3	2	110100000010001000000101	30		90							1			90							30		31		31	14		95.00		285.00																								285.00																		95.00					95.00			95.00				
H5696	030	0	1	01	01	H5696_030_0	13	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		30.00		90.00																								60.00																		30.00								30.00				
H5696	030	0	1	01	01	H5696_030_0	13	1	Preferred Generic	1	4	001010	1	2	110100000010001000000101	30		90							1			90							30		31		31	14		3.00		9.00																								6.00																		3.00					3.00			3.00				
H5696	030	0	1	01	01	H5696_030_0	13	4	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					580.50	33																							33																			33				33			33			
H5696	033	0	1	01	01	H5696_033_0	11	1	Preferred Generic	1	4	001010	1	2	110100000010001000000101	30		90							1			90							30		31		31	14		0.00		0.00																								0.00																		0.00					0.00			0.00				
H5696	033	0	1	01	01	H5696_033_0	11	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		20.00		60.00																								40.00																		20.00								20.00				
H5696	033	0	1	01	01	H5696_033_0	11	3	Non-Preferred Brand	1	4	110000	3	2	110100000010001000000101	30		90							1			90							30		31		31	14		80.00		240.00																								240.00																		80.00					80.00			80.00				
H5696	033	0	1	01	01	H5696_033_0	11	4	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					464.80	33																							33																			33				33			33			
H5696	033	0	1	01	01	H5696_033_0	11	1	Preferred Generic	3	4	001010	1	2	110100000010001000000101	30		90							1			90							30		31		31	14		0.00		0.00																								0.00																		0.00					0.00			0.00		1		
H5696	034	0	1	01	01	H5696_034_0	13	1	Preferred Generic	1	4	001010	1	2	110100000010001000000101	30		90							1			90							30		31		31	14		3.00		9.00																								6.00																		3.00					3.00			3.00				
H5696	034	0	1	01	01	H5696_034_0	13	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								70.00																		35.00								35.00				
H5696	034	0	1	01	01	H5696_034_0	13	4	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					503.15	33																							33																			33				33			33			
H5696	034	0	1	01	01	H5696_034_0	13	3	Non-Preferred Brand	1	4	110000	3	2	110100000010001000000101	30		90							1			90							30		31		31	14		95.00		285.00																								285.00																		95.00					95.00			95.00				
H5696	035	0	1	01	01	H5696_035_0	10	1	Preferred Generic	1	4	001010	1	2	110100000010001000000101	30		90							1			90							30		31		31	14		0.00		0.00																								0.00																		0.00					0.00			0.00				
H5696	035	0	1	01	01	H5696_035_0	10	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		15.00		45.00																								30.00																		15.00								15.00				
H5696	035	0	1	01	01	H5696_035_0	10	4	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					536.82	33																							33																			33				33			33			
H5696	035	0	1	01	01	H5696_035_0	10	3	Non-Preferred Brand	1	4	110000	3	2	110100000010001000000101	30		90							1			90							30		31		31	14		80.00		240.00																								240.00																		80.00					80.00			80.00				
H5696	035	0	1	01	01	H5696_035_0	10	1	Preferred Generic	3	4	001010	1	2	110100000010001000000101	30		90							1			90							30		31		31	14		0.00		0.00																								0.00																		0.00					0.00			0.00		1		
H5696	037	0	1	01	01	H5696_037_0	11	1	Preferred Generic	1	4	001010	1	2	110100000010001000000101	30		90							1			90							30		31		31	14		0.00		0.00																								0.00																		0.00					0.00			0.00				
H5696	037	0	1	01	01	H5696_037_0	11	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		20.00		60.00																								40.00																		20.00								20.00				
H5696	037	0	1	01	01	H5696_037_0	11	3	Non-Preferred Brand	1	4	110000	3	2	110100000010001000000101	30		90							1			90							30		31		31	14		80.00		240.00																								240.00																		80.00					80.00			80.00				
H5696	037	0	1	01	01	H5696_037_0	11	4	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					531.64	33																							33																			33				33			33			
H5696	037	0	1	01	01	H5696_037_0	11	1	Preferred Generic	3	4	001010	1	2	110100000010001000000101	30		90							1			90							30		31		31	14		0.00		0.00																								0.00																		0.00					0.00			0.00		1		
H5696	038	0	1	01	01	H5696_038_0	13	4	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					516.87	33																							33																			33				33			33			
H5696	038	0	1	01	01	H5696_038_0	13	3	Non-Preferred Brand	1	4	110000	3	2	110100000010001000000101	30		90							1			90							30		31		31	14		95.00		285.00																								285.00																		95.00					95.00			95.00				
H5696	038	0	1	01	01	H5696_038_0	13	1	Preferred Generic	1	4	001010	1	2	110100000010001000000101	30		90							1			90							30		31		31	14		3.00		9.00																								6.00																		3.00					3.00			3.00				
H5696	038	0	1	01	01	H5696_038_0	13	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								70.00																		35.00								35.00				
H5696	039	0	1	01	01	H5696_039_0	11	4	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					532.57	33																							33																			33				33			33			
H5696	039	0	1	01	01	H5696_039_0	11	3	Non-Preferred Brand	1	4	110000	3	2	110100000010001000000101	30		90							1			90							30		31		31	14		80.00		240.00																								240.00																		80.00					80.00			80.00				
H5696	039	0	1	01	01	H5696_039_0	11	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		20.00		60.00																								40.00																		20.00								20.00				
H5696	039	0	1	01	01	H5696_039_0	11	1	Preferred Generic	3	4	001010	1	2	110100000010001000000101	30		90							1			90							30		31		31	14		0.00		0.00																								0.00																		0.00					0.00			0.00		1		
H5696	039	0	1	01	01	H5696_039_0	11	1	Preferred Generic	1	4	001010	1	2	110100000010001000000101	30		90							1			90							30		31		31	14		0.00		0.00																								0.00																		0.00					0.00			0.00				
H5696	040	0	1	01	01	H5696_040_0	14	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		35.00		105.00																								70.00																		35.00								35.00				
H5696	040	0	1	01	01	H5696_040_0	14	1	Preferred Generic	1	4	001010	1	2	110100000010001000000101	30		90							1			90							30		31		31	14		3.00		9.00																								6.00																		3.00					3.00			3.00				
H5696	040	0	1	01	01	H5696_040_0	14	3	Non-Preferred Brand	1	4	110000	3	2	110100000010001000000101	30		90							1			90							30		31		31	14		95.00		285.00																								285.00																		95.00					95.00			95.00				
H5696	040	0	1	01	01	H5696_040_0	14	4	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					505.07	33																							33																			33				33			33			
H5696	041	0	1	01	01	H5696_041_0	13	1	Preferred Generic	1	4	001010	1	2	110100000010001000000101	30		90							1			90							30		31		31	14		0.00		0.00																								0.00																		0.00					0.00			0.00				
H5696	041	0	1	01	01	H5696_041_0	13	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		5.00		15.00																								10.00																		5.00								5.00				
H5696	041	0	1	01	01	H5696_041_0	13	3	Non-Preferred Brand	1	4	110000	3	2	110100000010001000000101	30		90							1			90							30		31		31	14		45.00		135.00																								115.00																		45.00					45.00			45.00				
H5696	041	0	1	01	01	H5696_041_0	13	4	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					531.55	33																							33																			33				33			33			
H5696	041	0	1	01	01	H5696_041_0	13	1	Preferred Generic	3	4	001010	1	2	110100000010001000000101	30		90							1			90							30		31		31	14		0.00		0.00																								0.00																		0.00					0.00			0.00		1		
H5696	043	0	1	01	01	H5696_043_0	12	1	Preferred Generic	1	4	001010	1	2	110100000010001000000101	30		90							1			90							30		31		31	14		0.00		0.00																								0.00																		0.00					0.00			0.00				
H5696	043	0	1	01	01	H5696_043_0	12	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		15.00		45.00																								30.00																		15.00								15.00				
H5696	043	0	1	01	01	H5696_043_0	12	3	Non-Preferred Brand	1	4	110000	3	2	110100000010001000000101	30		90							1			90							30		31		31	14		80.00		240.00																								240.00																		80.00					80.00			80.00				
H5696	043	0	1	01	01	H5696_043_0	12	4	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					597.37	33																							33																			33				33			33			
H5696	043	0	1	01	01	H5696_043_0	12	1	Preferred Generic	3	4	001010	1	2	110100000010001000000101	30		90							1			90							30		31		31	14		0.00		0.00																								0.00																		0.00					0.00			0.00		1		
H5698	020	0	1	01	01	H5698_020_0	9	1	Preferred Generic	1	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00							
H5698	020	0	1	01	01	H5698_020_0	9	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					10.00	20.00	30.00																													10.00	20.00	30.00					20.00	40.00	60.00				10.00					10.00							
H5698	020	0	1	01	01	H5698_020_0	9	1	Preferred Generic	3	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00					1		
H5698	020	0	1	01	01	H5698_020_0	9	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		67.00	134.00	201.00																													67.00	134.00	201.00					134.00	268.00	402.00				67.00								67.00				
H5698	020	0	1	01	01	H5698_020_0	9	5	Specialty Tier	1	4	010010	1	1	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14					718.72	33	33	33																												33	33	33					33	33	33			33				33			33			
H5698	020	0	1	01	01	H5698_020_0	9	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		43.00	86.00	129.00																													43.00	86.00	129.00					86.00	172.00	258.00				43.00								43.00				
H5698	028	0	1	01	01	H5698_028_0	10	1	Preferred Generic	3	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00					1		
H5698	028	0	1	01	01	H5698_028_0	10	1	Preferred Generic	1	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00							
H5698	028	0	1	01	01	H5698_028_0	10	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					10.00	20.00	30.00																													10.00	20.00	30.00					20.00	40.00	60.00				10.00					10.00							
H5698	028	0	1	01	01	H5698_028_0	10	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		43.00	86.00	129.00																													43.00	86.00	129.00					86.00	172.00	258.00				43.00								43.00				
H5698	028	0	1	01	01	H5698_028_0	10	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		67.00	134.00	201.00																													67.00	134.00	201.00					134.00	268.00	402.00				67.00								67.00				
H5698	028	0	1	01	01	H5698_028_0	10	5	Specialty Tier	1	4	010010	1	1	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14					563.61	33	33	33																												33	33	33					33	33	33			33				33			33			
H5698	036	0	1	01	01	H5698_036_0	9	5	Specialty Tier	1	4	010010	1	1	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14					482.39	33	33	33																												33	33	33					33	33	33			33				33			33			
H5698	036	0	1	01	01	H5698_036_0	9	1	Preferred Generic	3	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00					1		
H5698	036	0	1	01	01	H5698_036_0	9	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		43.00	86.00	129.00																													43.00	86.00	129.00					86.00	172.00	258.00				43.00								43.00				
H5698	036	0	1	01	01	H5698_036_0	9	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					10.00	20.00	30.00																													10.00	20.00	30.00					20.00	40.00	60.00				10.00					10.00							
H5698	036	0	1	01	01	H5698_036_0	9	1	Preferred Generic	1	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00							
H5698	036	0	1	01	01	H5698_036_0	9	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		67.00	134.00	201.00																													67.00	134.00	201.00					134.00	268.00	402.00				67.00								67.00				
H5698	061	0	1	01	01	H5698_061_0	8	1	Preferred Generic	1	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00							
H5698	061	0	1	01	01	H5698_061_0	8	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					10.00	20.00	30.00																													10.00	20.00	30.00					20.00	40.00	60.00				10.00					10.00							
H5698	061	0	1	01	01	H5698_061_0	8	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		45.00	90.00	135.00																													45.00	90.00	135.00					90.00	180.00	270.00				45.00								45.00				
H5698	061	0	1	01	01	H5698_061_0	8	5	Specialty Tier	1	4	010010	1	1	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14					542.82	33	33	33																												33	33	33					33	33	33			33				33			33			
H5698	061	0	1	01	01	H5698_061_0	8	1	Preferred Generic	3	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00					1		
H5698	061	0	1	01	01	H5698_061_0	8	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		70.00	140.00	210.00																													70.00	140.00	210.00					140.00	280.00	420.00				70.00								70.00				
H5698	062	0	1	01	01	H5698_062_0	8	5	Specialty Tier	1	4	010010	1	1	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14					516.89	33	33	33																												33	33	33					33	33	33			33				33			33			
H5698	062	0	1	01	01	H5698_062_0	8	1	Preferred Generic	3	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00					1		
H5698	062	0	1	01	01	H5698_062_0	8	1	Preferred Generic	1	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00							
H5698	062	0	1	01	01	H5698_062_0	8	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					10.00	20.00	30.00																													10.00	20.00	30.00					20.00	40.00	60.00				10.00					10.00							
H5698	062	0	1	01	01	H5698_062_0	8	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		70.00	140.00	210.00																													70.00	140.00	210.00					140.00	280.00	420.00				70.00								70.00				
H5698	062	0	1	01	01	H5698_062_0	8	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		45.00	90.00	135.00																													45.00	90.00	135.00					90.00	180.00	270.00				45.00								45.00				
H5698	063	0	1	01	01	H5698_063_0	8	1	Preferred Generic	3	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00					1		
H5698	063	0	1	01	01	H5698_063_0	8	5	Specialty Tier	1	4	010010	1	1	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14					730.50	33	33	33																												33	33	33					33	33	33			33				33			33			
H5698	063	0	1	01	01	H5698_063_0	8	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		70.00	140.00	210.00																													70.00	140.00	210.00					140.00	280.00	420.00				70.00								70.00				
H5698	063	0	1	01	01	H5698_063_0	8	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		45.00	90.00	135.00																													45.00	90.00	135.00					90.00	180.00	270.00				45.00								45.00				
H5698	063	0	1	01	01	H5698_063_0	8	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					10.00	20.00	30.00																													10.00	20.00	30.00					20.00	40.00	60.00				10.00					10.00							
H5698	063	0	1	01	01	H5698_063_0	8	1	Preferred Generic	1	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00							
H5698	067	0	1	01	01	H5698_067_0	8	5	Specialty Tier	1	4	010010	1	1	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14					553.53	33	33	33																												33	33	33					33	33	33			33				33			33			
H5698	067	0	1	01	01	H5698_067_0	8	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		65.00	130.00	195.00																													65.00	130.00	195.00					130.00	260.00	390.00				65.00								65.00				
H5698	067	0	1	01	01	H5698_067_0	8	1	Preferred Generic	1	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00							
H5698	067	0	1	01	01	H5698_067_0	8	1	Preferred Generic	3	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00					1		
H5698	067	0	1	01	01	H5698_067_0	8	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					10.00	20.00	30.00																													10.00	20.00	30.00					20.00	40.00	60.00				10.00					10.00							
H5698	067	0	1	01	01	H5698_067_0	8	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		40.00	80.00	120.00																													40.00	80.00	120.00					80.00	160.00	240.00				40.00								40.00				
H5698	068	0	1	01	01	H5698_068_0	8	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					10.00	20.00	30.00																													10.00	20.00	30.00					20.00	40.00	60.00				10.00					10.00							
H5698	068	0	1	01	01	H5698_068_0	8	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		65.00	130.00	195.00																													65.00	130.00	195.00					130.00	260.00	390.00				65.00								65.00				
H5698	068	0	1	01	01	H5698_068_0	8	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		40.00	80.00	120.00																													40.00	80.00	120.00					80.00	160.00	240.00				40.00								40.00				
H5698	068	0	1	01	01	H5698_068_0	8	1	Preferred Generic	1	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00							
H5698	068	0	1	01	01	H5698_068_0	8	5	Specialty Tier	1	4	010010	1	1	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14					522.61	33	33	33																												33	33	33					33	33	33			33				33			33			
H5698	068	0	1	01	01	H5698_068_0	8	1	Preferred Generic	3	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00					1		
H5698	069	0	1	01	01	H5698_069_0	8	1	Preferred Generic	1	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00							
H5698	069	0	1	01	01	H5698_069_0	8	5	Specialty Tier	1	4	010010	1	1	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14					673.66	33	33	33																												33	33	33					33	33	33			33				33			33			
H5698	069	0	1	01	01	H5698_069_0	8	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					10.00	20.00	30.00																													10.00	20.00	30.00					20.00	40.00	60.00				10.00					10.00							
H5698	069	0	1	01	01	H5698_069_0	8	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		40.00	80.00	120.00																													40.00	80.00	120.00					80.00	160.00	240.00				40.00								40.00				
H5698	069	0	1	01	01	H5698_069_0	8	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		65.00	130.00	195.00																													65.00	130.00	195.00					130.00	260.00	390.00				65.00								65.00				
H5698	069	0	1	01	01	H5698_069_0	8	1	Preferred Generic	3	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00					1		
H5698	129	0	1	01	01	H5698_129_0	8	1	Preferred Generic	3	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					5.00	10.00	15.00																													5.00	10.00	15.00					10.00	20.00	30.00				5.00					5.00					1		
H5698	129	0	1	01	01	H5698_129_0	8	5	Specialty Tier	1	4	010010	1	1	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14					448.03	33	33	33																												33	33	33					33	33	33			33				33			33			
H5698	129	0	1	01	01	H5698_129_0	8	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		40.00	80.00	120.00																													40.00	80.00	120.00					80.00	160.00	240.00				40.00								40.00				
H5698	129	0	1	01	01	H5698_129_0	8	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					10.00	20.00	30.00																													10.00	20.00	30.00					20.00	40.00	60.00				10.00					10.00							
H5698	129	0	1	01	01	H5698_129_0	8	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		60.00	120.00	180.00																													60.00	120.00	180.00					120.00	240.00	360.00				60.00								60.00				
H5698	129	0	1	01	01	H5698_129_0	8	1	Preferred Generic	1	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					5.00	10.00	15.00																													5.00	10.00	15.00					10.00	20.00	30.00				5.00					5.00							
H5698	141	0	1	01	01	H5698_141_0	7	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		60.00	120.00	180.00																													60.00	120.00	180.00					120.00	240.00	360.00				60.00								60.00				
H5698	141	0	1	01	01	H5698_141_0	7	1	Preferred Generic	1	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					5.00	10.00	15.00																													5.00	10.00	15.00					10.00	20.00	30.00				5.00					5.00							
H5698	141	0	1	01	01	H5698_141_0	7	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					10.00	20.00	30.00																													10.00	20.00	30.00					20.00	40.00	60.00				10.00					10.00							
H5698	141	0	1	01	01	H5698_141_0	7	5	Specialty Tier	1	4	010010	1	1	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14					462.92	33	33	33																												33	33	33					33	33	33			33				33			33			
H5698	141	0	1	01	01	H5698_141_0	7	1	Preferred Generic	3	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					5.00	10.00	15.00																													5.00	10.00	15.00					10.00	20.00	30.00				5.00					5.00					1		
H5698	141	0	1	01	01	H5698_141_0	7	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		40.00	80.00	120.00																													40.00	80.00	120.00					80.00	160.00	240.00				40.00								40.00				
H5698	153	0	1	01	01	H5698_153_0	6	1	Preferred Generic	3	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					4.00	8.00	12.00																													4.00	8.00	12.00					8.00	16.00	24.00				4.00					4.00					1		
H5698	153	0	1	01	01	H5698_153_0	6	5	Specialty Tier	1	4	010010	1	1	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14					451.14	33	33	33																												33	33	33					33	33	33			33				33			33			
H5698	153	0	1	01	01	H5698_153_0	6	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		40.00	80.00	120.00																													40.00	80.00	120.00					80.00	160.00	240.00				40.00								40.00				
H5698	153	0	1	01	01	H5698_153_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					10.00	20.00	30.00																													10.00	20.00	30.00					20.00	40.00	60.00				10.00					10.00							
H5698	153	0	1	01	01	H5698_153_0	6	1	Preferred Generic	1	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					4.00	8.00	12.00																													4.00	8.00	12.00					8.00	16.00	24.00				4.00					4.00							
H5698	153	0	1	01	01	H5698_153_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		60.00	120.00	180.00																													60.00	120.00	180.00					120.00	240.00	360.00				60.00								60.00				
H5698	154	0	1	01	01	H5698_154_0	7	1	Preferred Generic	1	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					4.00	8.00	12.00																													4.00	8.00	12.00					8.00	16.00	24.00				4.00					4.00							
H5698	154	0	1	01	01	H5698_154_0	7	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					10.00	20.00	30.00																													10.00	20.00	30.00					20.00	40.00	60.00				10.00					10.00							
H5698	154	0	1	01	01	H5698_154_0	7	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		40.00	80.00	120.00																													40.00	80.00	120.00					80.00	160.00	240.00				40.00								40.00				
H5698	154	0	1	01	01	H5698_154_0	7	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		60.00	120.00	180.00																													60.00	120.00	180.00					120.00	240.00	360.00				60.00								60.00				
H5698	154	0	1	01	01	H5698_154_0	7	5	Specialty Tier	1	4	010010	1	1	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14					451.67	33	33	33																												33	33	33					33	33	33			33				33			33			
H5698	154	0	1	01	01	H5698_154_0	7	1	Preferred Generic	3	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					4.00	8.00	12.00																													4.00	8.00	12.00					8.00	16.00	24.00				4.00					4.00					1		
H5698	155	0	1	01	01	H5698_155_0	8	5	Specialty Tier	1	4	010010	1	1	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14					530.03	33	33	33																												33	33	33					33	33	33			33				33			33			
H5698	155	0	1	01	01	H5698_155_0	8	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		60.00	120.00	180.00																													60.00	120.00	180.00					120.00	240.00	360.00				60.00								60.00				
H5698	155	0	1	01	01	H5698_155_0	8	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		40.00	80.00	120.00																													40.00	80.00	120.00					80.00	160.00	240.00				40.00								40.00				
H5698	155	0	1	01	01	H5698_155_0	8	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					10.00	20.00	30.00																													10.00	20.00	30.00					20.00	40.00	60.00				10.00					10.00							
H5698	155	0	1	01	01	H5698_155_0	8	1	Preferred Generic	1	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					4.00	8.00	12.00																													4.00	8.00	12.00					8.00	16.00	24.00				4.00					4.00							
H5698	155	0	1	01	01	H5698_155_0	8	1	Preferred Generic	3	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					4.00	8.00	12.00																													4.00	8.00	12.00					8.00	16.00	24.00				4.00					4.00					1		
H5698	156	0	1	01	01	H5698_156_0	8	5	Specialty Tier	1	4	010010	1	1	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14					618.32	33	33	33																												33	33	33					33	33	33			33				33			33			
H5698	156	0	1	01	01	H5698_156_0	8	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		60.00	120.00	180.00																													60.00	120.00	180.00					120.00	240.00	360.00				60.00								60.00				
H5698	156	0	1	01	01	H5698_156_0	8	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		40.00	80.00	120.00																													40.00	80.00	120.00					80.00	160.00	240.00				40.00								40.00				
H5698	156	0	1	01	01	H5698_156_0	8	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					10.00	20.00	30.00																													10.00	20.00	30.00					20.00	40.00	60.00				10.00					10.00							
H5698	156	0	1	01	01	H5698_156_0	8	1	Preferred Generic	1	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					4.00	8.00	12.00																													4.00	8.00	12.00					8.00	16.00	24.00				4.00					4.00							
H5698	156	0	1	01	01	H5698_156_0	8	1	Preferred Generic	3	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					4.00	8.00	12.00																													4.00	8.00	12.00					8.00	16.00	24.00				4.00					4.00					1		
H5698	157	0	1	01	01	H5698_157_0	9	5	Specialty Tier	1	4	010010	1	1	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14					564.70	33	33	33																												33	33	33					33	33	33			33				33			33			
H5698	157	0	1	01	01	H5698_157_0	9	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		67.00	134.00	201.00																													67.00	134.00	201.00					134.00	268.00	402.00				67.00								67.00				
H5698	157	0	1	01	01	H5698_157_0	9	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		43.00	86.00	129.00																													43.00	86.00	129.00					86.00	172.00	258.00				43.00								43.00				
H5698	157	0	1	01	01	H5698_157_0	9	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					10.00	20.00	30.00																													10.00	20.00	30.00					20.00	40.00	60.00				10.00					10.00							
H5698	157	0	1	01	01	H5698_157_0	9	1	Preferred Generic	1	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00							
H5698	157	0	1	01	01	H5698_157_0	9	1	Preferred Generic	3	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00					1		
H5698	159	0	1	01	01	H5698_159_0	7	5	Specialty Tier	1	4	010010	1	1	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14					779.28	33	33	33																												33	33	33					33	33	33			33				33			33			
H5698	159	0	1	01	01	H5698_159_0	7	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		70.00	140.00	210.00																													70.00	140.00	210.00					140.00	280.00	420.00				70.00								70.00				
H5698	159	0	1	01	01	H5698_159_0	7	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		45.00	90.00	135.00																													45.00	90.00	135.00					90.00	180.00	270.00				45.00								45.00				
H5698	159	0	1	01	01	H5698_159_0	7	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					10.00	20.00	30.00																													10.00	20.00	30.00					20.00	40.00	60.00				10.00					10.00							
H5698	159	0	1	01	01	H5698_159_0	7	1	Preferred Generic	1	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00							
H5698	159	0	1	01	01	H5698_159_0	7	1	Preferred Generic	3	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00					1		
H5698	160	0	1	01	01	H5698_160_0	7	5	Specialty Tier	1	4	010010	1	1	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14					557.09	33	33	33																												33	33	33					33	33	33			33				33			33			
H5698	160	0	1	01	01	H5698_160_0	7	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		65.00	130.00	195.00																													65.00	130.00	195.00					130.00	260.00	390.00				65.00								65.00				
H5698	160	0	1	01	01	H5698_160_0	7	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		40.00	80.00	120.00																													40.00	80.00	120.00					80.00	160.00	240.00				40.00								40.00				
H5698	160	0	1	01	01	H5698_160_0	7	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					10.00	20.00	30.00																													10.00	20.00	30.00					20.00	40.00	60.00				10.00					10.00							
H5698	160	0	1	01	01	H5698_160_0	7	1	Preferred Generic	1	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00							
H5698	160	0	1	01	01	H5698_160_0	7	1	Preferred Generic	3	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00					1		
H5698	163	0	1	01	01	H5698_163_0	8	1	Preferred Generic	1	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					4.00	8.00	12.00																													4.00	8.00	12.00					8.00	16.00	24.00				4.00					4.00							
H5698	163	0	1	01	01	H5698_163_0	8	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					10.00	20.00	30.00																													10.00	20.00	30.00					20.00	40.00	60.00				10.00					10.00							
H5698	163	0	1	01	01	H5698_163_0	8	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		40.00	80.00	120.00																													40.00	80.00	120.00					80.00	160.00	240.00				40.00								40.00				
H5698	163	0	1	01	01	H5698_163_0	8	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		60.00	120.00	180.00																													60.00	120.00	180.00					120.00	240.00	360.00				60.00								60.00				
H5698	163	0	1	01	01	H5698_163_0	8	5	Specialty Tier	1	4	010010	1	1	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14					450.97	33	33	33																												33	33	33					33	33	33			33				33			33			
H5698	163	0	1	01	01	H5698_163_0	8	1	Preferred Generic	3	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					4.00	8.00	12.00																													4.00	8.00	12.00					8.00	16.00	24.00				4.00					4.00					1		
H5698	164	0	1	01	01	H5698_164_0	7	1	Preferred Generic	3	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00					1		
H5698	164	0	1	01	01	H5698_164_0	7	5	Specialty Tier	1	4	010010	1	1	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14					630.19	33	33	33																												33	33	33					33	33	33			33				33			33			
H5698	164	0	1	01	01	H5698_164_0	7	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		70.00	140.00	210.00																													70.00	140.00	210.00					140.00	280.00	420.00				70.00								70.00				
H5698	164	0	1	01	01	H5698_164_0	7	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		45.00	90.00	135.00																													45.00	90.00	135.00					90.00	180.00	270.00				45.00								45.00				
H5698	164	0	1	01	01	H5698_164_0	7	1	Preferred Generic	1	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00							
H5698	164	0	1	01	01	H5698_164_0	7	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					10.00	20.00	30.00																													10.00	20.00	30.00					20.00	40.00	60.00				10.00					10.00							
H5698	165	0	1	01	01	H5698_165_0	9	5	Specialty Tier	1	4	010010	1	1	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14					498.22	33	33	33																												33	33	33					33	33	33			33				33			33			
H5698	165	0	1	01	01	H5698_165_0	9	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		67.00	134.00	201.00																													67.00	134.00	201.00					134.00	268.00	402.00				67.00								67.00				
H5698	165	0	1	01	01	H5698_165_0	9	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		43.00	86.00	129.00																													43.00	86.00	129.00					86.00	172.00	258.00				43.00								43.00				
H5698	165	0	1	01	01	H5698_165_0	9	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					10.00	20.00	30.00																													10.00	20.00	30.00					20.00	40.00	60.00				10.00					10.00							
H5698	165	0	1	01	01	H5698_165_0	9	1	Preferred Generic	1	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00							
H5698	165	0	1	01	01	H5698_165_0	9	1	Preferred Generic	3	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00					1		
H5698	166	0	1	01	01	H5698_166_0	6	1	Preferred Generic	1	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00							
H5698	166	0	1	01	01	H5698_166_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					10.00	20.00	30.00																													10.00	20.00	30.00					20.00	40.00	60.00				10.00					10.00							
H5698	166	0	1	01	01	H5698_166_0	6	1	Preferred Generic	3	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00					1		
H5698	166	0	1	01	01	H5698_166_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		65.00	130.00	195.00																													65.00	130.00	195.00					130.00	260.00	390.00				65.00								65.00				
H5698	166	0	1	01	01	H5698_166_0	6	5	Specialty Tier	1	4	010010	1	1	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14					560.18	33	33	33																												33	33	33					33	33	33			33				33			33			
H5698	166	0	1	01	01	H5698_166_0	6	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		40.00	80.00	120.00																													40.00	80.00	120.00					80.00	160.00	240.00				40.00								40.00				
H5698	169	0	1	01	01	H5698_169_0	9	5	Specialty Tier	1	4	010010	1	1	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14					647.60	33	33	33																												33	33	33					33	33	33			33				33			33			
H5698	169	0	1	01	01	H5698_169_0	9	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		70.00	140.00	210.00																													70.00	140.00	210.00					140.00	280.00	420.00				70.00								70.00				
H5698	169	0	1	01	01	H5698_169_0	9	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		45.00	90.00	135.00																													45.00	90.00	135.00					90.00	180.00	270.00				45.00								45.00				
H5698	169	0	1	01	01	H5698_169_0	9	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					10.00	20.00	30.00																													10.00	20.00	30.00					20.00	40.00	60.00				10.00					10.00							
H5698	169	0	1	01	01	H5698_169_0	9	1	Preferred Generic	1	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00							
H5698	169	0	1	01	01	H5698_169_0	9	1	Preferred Generic	3	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00					1		
H5698	170	0	1	01	01	H5698_170_0	8	5	Specialty Tier	1	4	010010	1	1	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14					509.01	33	33	33																												33	33	33					33	33	33			33				33			33			
H5698	170	0	1	01	01	H5698_170_0	8	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		67.00	134.00	201.00																													67.00	134.00	201.00					134.00	268.00	402.00				67.00								67.00				
H5698	170	0	1	01	01	H5698_170_0	8	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		43.00	86.00	129.00																													43.00	86.00	129.00					86.00	172.00	258.00				43.00								43.00				
H5698	170	0	1	01	01	H5698_170_0	8	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					10.00	20.00	30.00																													10.00	20.00	30.00					20.00	40.00	60.00				10.00					10.00							
H5698	170	0	1	01	01	H5698_170_0	8	1	Preferred Generic	1	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00							
H5698	170	0	1	01	01	H5698_170_0	8	1	Preferred Generic	3	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00					1		
H5698	171	0	1	01	01	H5698_171_0	6	1	Preferred Generic	1	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00							
H5698	171	0	1	01	01	H5698_171_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					10.00	20.00	30.00																													10.00	20.00	30.00					20.00	40.00	60.00				10.00					10.00							
H5698	171	0	1	01	01	H5698_171_0	6	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		40.00	80.00	120.00																													40.00	80.00	120.00					80.00	160.00	240.00				40.00								40.00				
H5698	171	0	1	01	01	H5698_171_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		65.00	130.00	195.00																													65.00	130.00	195.00					130.00	260.00	390.00				65.00								65.00				
H5698	171	0	1	01	01	H5698_171_0	6	5	Specialty Tier	1	4	010010	1	1	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14					556.51	33	33	33																												33	33	33					33	33	33			33				33			33			
H5698	171	0	1	01	01	H5698_171_0	6	1	Preferred Generic	3	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00					1		
H5698	174	0	1	01	01	H5698_174_0	8	1	Preferred Generic	3	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00					1		
H5698	174	0	1	01	01	H5698_174_0	8	5	Specialty Tier	1	4	010010	1	1	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14					649.46	33	33	33																												33	33	33					33	33	33			33				33			33			
H5698	174	0	1	01	01	H5698_174_0	8	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		70.00	140.00	210.00																													70.00	140.00	210.00					140.00	280.00	420.00				70.00								70.00				
H5698	174	0	1	01	01	H5698_174_0	8	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		45.00	90.00	135.00																													45.00	90.00	135.00					90.00	180.00	270.00				45.00								45.00				
H5698	174	0	1	01	01	H5698_174_0	8	1	Preferred Generic	1	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00							
H5698	174	0	1	01	01	H5698_174_0	8	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					10.00	20.00	30.00																													10.00	20.00	30.00					20.00	40.00	60.00				10.00					10.00							
H5698	175	0	1	01	01	H5698_175_0	8	5	Specialty Tier	1	4	010010	1	1	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14					530.39	33	33	33																												33	33	33					33	33	33			33				33			33			
H5698	175	0	1	01	01	H5698_175_0	8	1	Preferred Generic	1	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00							
H5698	175	0	1	01	01	H5698_175_0	8	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					10.00	20.00	30.00																													10.00	20.00	30.00					20.00	40.00	60.00				10.00					10.00							
H5698	175	0	1	01	01	H5698_175_0	8	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		43.00	86.00	129.00																													43.00	86.00	129.00					86.00	172.00	258.00				43.00								43.00				
H5698	175	0	1	01	01	H5698_175_0	8	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		67.00	134.00	201.00																													67.00	134.00	201.00					134.00	268.00	402.00				67.00								67.00				
H5698	175	0	1	01	01	H5698_175_0	8	1	Preferred Generic	3	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00					1		
H5698	176	0	1	01	01	H5698_176_0	7	1	Preferred Generic	1	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00							
H5698	176	0	1	01	01	H5698_176_0	7	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					10.00	20.00	30.00																													10.00	20.00	30.00					20.00	40.00	60.00				10.00					10.00							
H5698	176	0	1	01	01	H5698_176_0	7	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		40.00	80.00	120.00																													40.00	80.00	120.00					80.00	160.00	240.00				40.00								40.00				
H5698	176	0	1	01	01	H5698_176_0	7	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		65.00	130.00	195.00																													65.00	130.00	195.00					130.00	260.00	390.00				65.00								65.00				
H5698	176	0	1	01	01	H5698_176_0	7	5	Specialty Tier	1	4	010010	1	1	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14					570.49	33	33	33																												33	33	33					33	33	33			33				33			33			
H5698	176	0	1	01	01	H5698_176_0	7	1	Preferred Generic	3	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00					1		
H5698	178	0	1	01	01	H5698_178_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					10.00	20.00	30.00																													10.00	20.00	30.00					20.00	40.00	60.00				10.00					10.00							
H5698	178	0	1	01	01	H5698_178_0	6	1	Preferred Generic	1	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00							
H5698	178	0	1	01	01	H5698_178_0	6	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		45.00	90.00	135.00																													45.00	90.00	135.00					90.00	180.00	270.00				45.00								45.00				
H5698	178	0	1	01	01	H5698_178_0	6	1	Preferred Generic	3	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00					1		
H5698	178	0	1	01	01	H5698_178_0	6	5	Specialty Tier	1	4	010010	1	1	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14					637.81	33	33	33																												33	33	33					33	33	33			33				33			33			
H5698	178	0	1	01	01	H5698_178_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		70.00	140.00	210.00																													70.00	140.00	210.00					140.00	280.00	420.00				70.00								70.00				
H5698	179	0	1	01	01	H5698_179_0	7	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					10.00	20.00	30.00																													10.00	20.00	30.00					20.00	40.00	60.00				10.00					10.00							
H5698	179	0	1	01	01	H5698_179_0	7	1	Preferred Generic	1	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00							
H5698	179	0	1	01	01	H5698_179_0	7	1	Preferred Generic	3	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00					1		
H5698	179	0	1	01	01	H5698_179_0	7	5	Specialty Tier	1	4	010010	1	1	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14					521.75	33	33	33																												33	33	33					33	33	33			33				33			33			
H5698	179	0	1	01	01	H5698_179_0	7	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		67.00	134.00	201.00																													67.00	134.00	201.00					134.00	268.00	402.00				67.00								67.00				
H5698	179	0	1	01	01	H5698_179_0	7	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		43.00	86.00	129.00																													43.00	86.00	129.00					86.00	172.00	258.00				43.00								43.00				
H5698	180	0	1	01	01	H5698_180_0	6	1	Preferred Generic	1	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00							
H5698	180	0	1	01	01	H5698_180_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					10.00	20.00	30.00																													10.00	20.00	30.00					20.00	40.00	60.00				10.00					10.00							
H5698	180	0	1	01	01	H5698_180_0	6	1	Preferred Generic	3	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00					1		
H5698	180	0	1	01	01	H5698_180_0	6	5	Specialty Tier	1	4	010010	1	1	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14					563.51	33	33	33																												33	33	33					33	33	33			33				33			33			
H5698	180	0	1	01	01	H5698_180_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		65.00	130.00	195.00																													65.00	130.00	195.00					130.00	260.00	390.00				65.00								65.00				
H5698	180	0	1	01	01	H5698_180_0	6	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		40.00	80.00	120.00																													40.00	80.00	120.00					80.00	160.00	240.00				40.00								40.00				
H5698	182	0	1	01	01	H5698_182_0	7	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		70.00	140.00	210.00																													70.00	140.00	210.00					140.00	280.00	420.00				70.00								70.00				
H5698	182	0	1	01	01	H5698_182_0	7	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		45.00	90.00	135.00																													45.00	90.00	135.00					90.00	180.00	270.00				45.00								45.00				
H5698	182	0	1	01	01	H5698_182_0	7	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					10.00	20.00	30.00																													10.00	20.00	30.00					20.00	40.00	60.00				10.00					10.00							
H5698	182	0	1	01	01	H5698_182_0	7	1	Preferred Generic	1	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00							
H5698	182	0	1	01	01	H5698_182_0	7	1	Preferred Generic	3	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00					1		
H5698	182	0	1	01	01	H5698_182_0	7	5	Specialty Tier	1	4	010010	1	1	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14					642.64	33	33	33																												33	33	33					33	33	33			33				33			33			
H5698	183	0	1	01	01	H5698_183_0	7	1	Preferred Generic	3	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00					1		
H5698	183	0	1	01	01	H5698_183_0	7	5	Specialty Tier	1	4	010010	1	1	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14					530.26	33	33	33																												33	33	33					33	33	33			33				33			33			
H5698	183	0	1	01	01	H5698_183_0	7	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		67.00	134.00	201.00																													67.00	134.00	201.00					134.00	268.00	402.00				67.00								67.00				
H5698	183	0	1	01	01	H5698_183_0	7	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					10.00	20.00	30.00																													10.00	20.00	30.00					20.00	40.00	60.00				10.00					10.00							
H5698	183	0	1	01	01	H5698_183_0	7	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		43.00	86.00	129.00																													43.00	86.00	129.00					86.00	172.00	258.00				43.00								43.00				
H5698	183	0	1	01	01	H5698_183_0	7	1	Preferred Generic	1	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00							
H5698	184	0	1	01	01	H5698_184_0	6	1	Preferred Generic	1	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00							
H5698	184	0	1	01	01	H5698_184_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					10.00	20.00	30.00																													10.00	20.00	30.00					20.00	40.00	60.00				10.00					10.00							
H5698	184	0	1	01	01	H5698_184_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		65.00	130.00	195.00																													65.00	130.00	195.00					130.00	260.00	390.00				65.00								65.00				
H5698	184	0	1	01	01	H5698_184_0	6	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		40.00	80.00	120.00																													40.00	80.00	120.00					80.00	160.00	240.00				40.00								40.00				
H5698	184	0	1	01	01	H5698_184_0	6	1	Preferred Generic	3	4	001000	1	2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					3.00	6.00	9.00																													3.00	6.00	9.00					6.00	12.00	18.00				3.00					3.00					1		
H5698	184	0	1	01	01	H5698_184_0	6	5	Specialty Tier	1	4	010010	1	1	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14					560.23	33	33	33																												33	33	33					33	33	33			33				33			33			
H5732	001	0	1	01	01	H5732_001_0	8	1	Generic	1	4	010010	3	2	110100000010001000000111	30		90							2			90							30		31	14	31	14		5.00		15.00																								10.00																		5.00					5.00			5.00				
H5732	001	0	1	01	01	H5732_001_0	8	2	Preferred Brand	1	4	010001	3	2	110100000010001000000111	30		90							2			90							30		31	14	31	14		30.00		90.00																								60.00																		30.00					30.00			30.00				
H5732	001	0	1	01	01	H5732_001_0	8	1	Generic	3	4	010010	3	2	110100000010001000000111	30		90							2			90							30		31	14	31	14		5.00		15.00																								10.00																		5.00					5.00			5.00		1		
H5732	001	0	1	01	01	H5732_001_0	8	4	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							2			90							30		31	14	31	14					586.68	25		25																							25																	25				25			25			
H5732	001	0	1	01	01	H5732_001_0	8	3	Non-Preferred Brand	1	4	110000	3	2	110100000010001000000111	30		90							2			90							30		31	14	31	14		50.00		150.00																								100.00																		50.00					50.00			50.00				
H5746	006	0	1	01	01	H5746_006_0	7	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	31	62	93							2	31	62	93							31		31	1				0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00					1		
H5746	006	0	1	01	01	H5746_006_0	7	5	Specialty Tier	1	4	100100	1	1	111100000010111000000111	31	62	93							2	31	62	93							31		31	1	31	1					665.00	25	25	25																					25	25	25																	25				25			25			
H5746	006	0	1	01	01	H5746_006_0	7	4	Non-Preferred Brand	1	4	100000	1	1	111100000010111000000001	31	62	93							2	31	62	93							31				31	1					64.00	25	25	25																					25	25	25																	25							25			
H5746	006	0	1	01	01	H5746_006_0	7	3	Preferred Brand	1	4	000001	1	1	111100000010111000000001	31	62	93							2	31	62	93							31				31	1					42.00	25	25	25																					25	25	25																	25							25			
H5746	006	0	1	01	01	H5746_006_0	7	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	31	62	93							2	31	62	93							31		31	1				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	7	2	Non-Preferred Generic	3	4	000100	1	2	011100000010111000000110	31	62	93							2	31	62	93							31		31	1				0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00					1		
H5746	006	0	1	01	01	H5746_006_0	7	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	31	62	93							2	31	62	93							31		31	1				0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00							
H5746	012	0	1	01	01	H5746_012_0	10	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	31	62	93							2	31	62	93							31		31	1				0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00					1		
H5746	012	0	1	01	01	H5746_012_0	10	5	Specialty Tier	1	4	100100	1	1	111100000010111000000111	31	62	93							2	31	62	93							31		31	1	31	1					565.00	25	25	25																					25	25	25																	25				25			25			
H5746	012	0	1	01	01	H5746_012_0	10	4	Non-Preferred Brand	1	4	100000	1	1	111100000010111000000001	31	62	93							2	31	62	93							31				31	1					68.00	25	25	25																					25	25	25																	25							25			
H5746	012	0	1	01	01	H5746_012_0	10	3	Preferred Brand	1	4	000001	1	1	111100000010111000000001	31	62	93							2	31	62	93							31				31	1					45.00	25	25	25																					25	25	25																	25							25			
H5746	012	0	1	01	01	H5746_012_0	10	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	31	62	93							2	31	62	93							31		31	1				0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00							
H5746	012	0	1	01	01	H5746_012_0	10	2	Non-Preferred Generic	1	4	000100	1	1	011100000010111000000110	31	62	93							2	31	62	93							31		31	1							8.00	25	25	25																					25	25	25																	25				25						
H5749	001	0	1	02	01	H5749_001_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00							
H5749	001	0	1	02	01	H5749_001_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H5749	001	0	1	02	01	H5749_001_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H5749	001	0	1	02	01	H5749_001_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H5749	001	0	1	02	01	H5749_001_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					506.00	33		33																														33							33			33				33			33			
H5774	005	0	1	01	01	H5774_005_0	10	1	Preferred Generic	1	4	001000	1	2	010100000001101000000110	30		90							1	30		90								10	31	7				5.00		15.00																						5.00		10.00																			5.00				5.00							
H5774	005	0	1	01	01	H5774_005_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000001101000000110	30		90							1	30		90								10	31	7				10.00		30.00																						10.00		20.00																			10.00				10.00							
H5774	005	0	1	01	01	H5774_005_0	10	3	Preferred Brand	1	4	000001	1	2	110100000001101000000001	30		90							1	30		90								10			31	7		35.00		105.00																						35.00		70.00																			35.00							35.00				
H5774	005	0	1	01	01	H5774_005_0	10	4	Non-Preferred Brand	1	4	100000	1	2	110100000001101000000001	30		90							1	30		90								10			31	7		50.00		150.00																						50.00		100.00																			50.00							50.00				
H5774	005	0	1	01	01	H5774_005_0	10	5	Specialty Tier	1	4	010010	1	1	110100000001101000000111	30		90							1	30		90								10	31	7	31	7					674.44	33		33																					33		33																		33			33			33			
H5774	005	0	1	01	01	H5774_005_0	10	1	Preferred Generic	3	4	001000	1	2	010100000001101000000110	30		90							1	30		90								10	31	7				5.00		15.00																						5.00		10.00																			5.00				5.00					1		
H5774	005	0	1	01	01	H5774_005_0	10	2	Non-Preferred Generic	3	4	000100	1	2	010100000001101000000110	30		90							1	30		90								10	31	7				10.00		30.00																						10.00		20.00																			10.00				10.00					1		
H5774	008	0	1	01	01	H5774_008_0	9	2	Non-Preferred Generic	3	4	000100	1	2	010100000001101000000110	30		90							1	30		90								10	31	7				15.00		45.00																						15.00		30.00																			15.00				15.00					1		
H5774	008	0	1	01	01	H5774_008_0	9	1	Preferred Generic	3	4	001000	1	2	010100000001101000000110	30		90							1	30		90								10	31	7				7.00		21.00																						7.00		14.00																			7.00				7.00					1		
H5774	008	0	1	01	01	H5774_008_0	9	5	Specialty Tier	1	4	010010	1	1	110100000001101000000111	30		90							1	30		90								10	31	7	31	7					1260.37	33		33																					33		33																		33			33			33			
H5774	008	0	1	01	01	H5774_008_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000001101000000001	30		90							1	30		90								10			31	7		50.00		150.00																						50.00		100.00																			50.00							50.00				
H5774	008	0	1	01	01	H5774_008_0	9	3	Preferred Brand	1	4	000001	1	2	110100000001101000000001	30		90							1	30		90								10			31	7		35.00		105.00																						35.00		70.00																			35.00							35.00				
H5774	008	0	1	01	01	H5774_008_0	9	1	Preferred Generic	1	4	001000	1	2	010100000001101000000110	30		90							1	30		90								10	31	7				7.00		21.00																						7.00		14.00																			7.00				7.00							
H5774	008	0	1	01	01	H5774_008_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000001101000000110	30		90							1	30		90								10	31	7				15.00		45.00																						15.00		30.00																			15.00				15.00							
H5774	009	0	1	01	01	H5774_009_0	9	1	Preferred Generic	1	4	001000	1	2	010100000001101000000110	30		90							1	30		90								10	31	7				7.00		21.00																						7.00		14.00																			7.00				7.00							
H5774	009	0	1	01	01	H5774_009_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000001101000000110	30		90							1	30		90								10	31	7				15.00		45.00																						15.00		30.00																			15.00				15.00							
H5774	009	0	1	01	01	H5774_009_0	9	3	Preferred Brand	1	4	000001	1	2	110100000001101000000001	30		90							1	30		90								10			31	7		35.00		105.00																						35.00		70.00																			35.00							35.00				
H5774	009	0	1	01	01	H5774_009_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000001101000000001	30		90							1	30		90								10			31	7		50.00		150.00																						50.00		100.00																			50.00							50.00				
H5774	009	0	1	01	01	H5774_009_0	9	5	Specialty Tier	1	4	010010	1	1	110100000001101000000111	30		90							1	30		90								10	31	7	31	7					267.35	33		33																					33		33																		33			33			33			
H5774	009	0	1	01	01	H5774_009_0	9	1	Preferred Generic	3	4	001000	1	2	010100000001101000000110	30		90							1	30		90								10	31	7				7.00		21.00																						7.00		14.00																			7.00				7.00					1		
H5774	009	0	1	01	01	H5774_009_0	9	2	Non-Preferred Generic	3	4	000100	1	2	010100000001101000000110	30		90							1	30		90								10	31	7				15.00		45.00																						15.00		30.00																			15.00				15.00					1		
H5774	014	0	1	02	01	H5774_014_0	11	1	Preferred Generic	3	4	001000	1	2	010100000001101000000110	30		90							1	30		90								10	31	7				7.00		21.00																						7.00		14.00																			7.00				7.00					1		
H5774	014	0	1	02	01	H5774_014_0	11	5	Specialty Tier	1	4	010010	1	1	110100000001101000000111	30		90							1	30		90								10	31	7	31	7					463.54	33		33																					33		33																		33			33			33			
H5774	014	0	1	02	01	H5774_014_0	11	4	Non-Preferred Brand	1	4	100000	1	2	110100000001101000000001	30		90							1	30		90								10			31	7		50.00		150.00																						50.00		100.00																			50.00							50.00				
H5774	014	0	1	02	01	H5774_014_0	11	3	Preferred Brand	1	4	000001	1	2	110100000001101000000001	30		90							1	30		90								10			31	7		35.00		105.00																						35.00		70.00																			35.00							35.00				
H5774	014	0	1	02	01	H5774_014_0	11	2	Non-Preferred Generic	1	4	000100	1	2	010100000001101000000110	30		90							1	30		90								10	31	7				15.00		45.00																						15.00		30.00																			15.00				15.00							
H5774	014	0	1	02	01	H5774_014_0	11	1	Preferred Generic	1	4	001000	1	2	010100000001101000000110	30		90							1	30		90								10	31	7				7.00		21.00																						7.00		14.00																			7.00				7.00							
H5774	014	0	1	02	01	H5774_014_0	11	2	Non-Preferred Generic	3	4	000100	1	2	010100000001101000000110	30		90							1	30		90								10	31	7				15.00		45.00																						15.00		30.00																			15.00				15.00					1		
H5782	001	0	1	01	01	H5782_001_0	6	2	Brand	1	4	000010	1	2	110100000001101000000001	30		90							1	30		90								29			31	14		45.00		135.00																						45.00		135.00																			45.00							45.00				
H5782	001	0	1	01	01	H5782_001_0	6	1	Generic	1	4	010000	1	2	010100000001101000000100	30		90							1	30		90								29	31					0.00		0.00																						0.00		0.00																			0.00				0.00							
H5782	001	0	1	01	01	H5782_001_0	6	1	Generic	3	4	010000	1	2	010100000001101000000100	30		90							1	30		90								29	31					0.00		0.00																						0.00		0.00																			0.00				0.00					1		
H5783	002	0	1	01	01	H5783_002_0	8	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00				
H5783	002	0	1	01	01	H5783_002_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					508.00	33																														33							33					33				33			33			
H5783	002	0	1	01	01	H5783_002_0	8	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00		2	3	1
H5783	002	0	1	01	01	H5783_002_0	8	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H5783	002	0	1	01	01	H5783_002_0	8	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H5783	002	0	1	01	01	H5783_002_0	8	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H5783	002	0	1	01	01	H5783_002_0	8	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H5783	002	0	1	01	01	H5783_002_0	8	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00				
H5783	002	0	1	01	01	H5783_002_0	8	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00		2	3	
H5783	002	0	1	01	01	H5783_002_0	8	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1612.00	33																														33							33					33				33			33	2	3	
H5783	006	0	1	01	01	H5783_006_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		3.00		9.00																													0.00		0.00					3.00		9.00				3.00					3.00			3.00				
H5783	006	0	1	01	01	H5783_006_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00				
H5783	006	0	1	01	01	H5783_006_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H5783	006	0	1	01	01	H5783_006_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H5783	006	0	1	01	01	H5783_006_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					3134.00	33																														33							33					33				33			33	2	3	
H5783	006	0	1	01	01	H5783_006_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		3.00		9.00																													0.00		0.00					3.00		9.00				3.00					3.00			3.00		2	3	1
H5783	006	0	1	01	01	H5783_006_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00		2	2	
H5783	006	0	1	01	01	H5783_006_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H5783	006	0	1	01	01	H5783_006_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H5783	006	0	1	01	01	H5783_006_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1023.00	33																														33							33					33				33			33			
H5783	008	0	1	01	01	H5783_008_0	9	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H5783	008	0	1	01	01	H5783_008_0	9	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H5783	008	0	1	01	01	H5783_008_0	9	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		43.00		129.00																													43.00		119.00					43.00		129.00				43.00					43.00			43.00				
H5783	008	0	1	01	01	H5783_008_0	9	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		94.00		282.00																													94.00		272.00					94.00		282.00				94.00					94.00			94.00				
H5783	008	0	1	01	01	H5783_008_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					280.45	25																														25							25					25				25			25			
H5793	001	0	1	01	01	H5793_001_0	6	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					199.06	33	33	33																												33	33	33					33	33	33				33			33			33			
H5793	001	0	1	01	01	H5793_001_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H5793	001	0	1	01	01	H5793_001_0	6	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H5793	001	0	1	01	01	H5793_001_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H5793	001	0	1	01	01	H5793_001_0	6	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					6.00	12.00	18.00																													6.00	12.00	12.00					6.00	12.00	18.00					6.00				6.00							
H5793	008	0	1	01	01	H5793_008_0	6	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					246.43	33	33	33																												33	33	33					33	33	33				33			33			33			
H5793	008	0	1	01	01	H5793_008_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H5793	008	0	1	01	01	H5793_008_0	6	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H5793	008	0	1	01	01	H5793_008_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H5793	008	0	1	01	01	H5793_008_0	6	1	Preferred Generic	3	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					6.00	12.00	18.00																													6.00	12.00	12.00					6.00	12.00	18.00					6.00				6.00					1		
H5793	008	0	1	01	01	H5793_008_0	6	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					6.00	12.00	18.00																													6.00	12.00	12.00					6.00	12.00	18.00					6.00				6.00							
H5810	001	0	1	01	01	H5810_001_0	8	1	Generic	1	4	010000	1	2	011100000010111000000110	31	60	90							1	31	60	90							31		31	14				0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00							
H5810	001	0	1	01	01	H5810_001_0	8	4	Specialty Tier	1	4	010010	1	1	110000000010100000000111	31										31									31		31	14	31	14					512.94	25																							25																			25				25			25			
H5810	001	0	1	01	01	H5810_001_0	8	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	31	60	90							1	31	60	90							31				31	14		45.00	90.00	135.00																						45.00	90.00	135.00																		45.00								45.00				
H5810	001	0	1	01	01	H5810_001_0	8	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	31	60	90							1	31	60	90							31				31	14		95.00	190.00	285.00																						95.00	190.00	285.00																		95.00								95.00				
H5811	001	0	1	01	01	H5811_001_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	31		90							1			90							31				31	14		35.00		105.00																								70.00																		35.00								35.00				
H5811	001	0	1	01	01	H5811_001_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	31		90							1			90							31		31	14				10.00		30.00																								20.00																		10.00					10.00							
H5811	001	0	1	01	01	H5811_001_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				5.00		15.00																								10.00																		5.00					5.00							
H5811	001	0	1	01	01	H5811_001_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	31		90							1			90							31				31	14		55.00		165.00																								110.00																		55.00								55.00				
H5811	001	0	1	01	01	H5811_001_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010000000000111	31																			31		31	14	31	14					537.04	33																																										33				33			33			
H5811	001	0	1	01	01	H5811_001_0	9	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				5.00		15.00																								10.00																		5.00					5.00					1		
H5811	001	0	1	01	01	H5811_001_0	9	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	31		90							1			90							31		31	14				10.00		30.00																								20.00																		10.00					10.00					1		
H5811	001	0	1	01	01	H5811_001_0	9	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	31		90							1			90							31				31	14		10.00		30.00																								20.00																		10.00								10.00				
H5811	005	0	1	01	01	H5811_005_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	31		90							1			90							31		31	14				10.00		30.00																								20.00																		10.00					10.00							
H5811	005	0	1	01	01	H5811_005_0	10	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	31		90							1			90							31				31	14		10.00		30.00																								20.00																		10.00								10.00				
H5811	005	0	1	01	01	H5811_005_0	10	5	Specialty Tier	1	4	010010	1	1	110000000010000000000111	31																			31		31	14	31	14					701.58	33																																										33				33			33			
H5811	005	0	1	01	01	H5811_005_0	10	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	31		90							1			90							31				31	14		75.00		225.00																								150.00																		75.00								75.00				
H5811	005	0	1	01	01	H5811_005_0	10	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	31		90							1			90							31				31	14		45.00		135.00																								90.00																		45.00								45.00				
H5811	005	0	1	01	01	H5811_005_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				5.00		15.00																								10.00																		5.00					5.00							
H5813	003	0	1	01	01	H5813_003_0	6	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					357.69	33	33	33																												33	33	33					33	33	33				33			33			33			
H5813	003	0	1	01	01	H5813_003_0	6	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					6.00	12.00	18.00																													6.00	12.00	12.00					6.00	12.00	18.00					6.00				6.00							
H5813	003	0	1	01	01	H5813_003_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H5813	003	0	1	01	01	H5813_003_0	6	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H5813	003	0	1	01	01	H5813_003_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H5813	006	0	1	01	01	H5813_006_0	6	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					279.91	33	33	33																												33	33	33					33	33	33				33			33			33			
H5813	006	0	1	01	01	H5813_006_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H5813	006	0	1	01	01	H5813_006_0	6	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					6.00	12.00	18.00																													6.00	12.00	12.00					6.00	12.00	18.00					6.00				6.00							
H5813	006	0	1	01	01	H5813_006_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H5813	006	0	1	01	01	H5813_006_0	6	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H5813	006	0	1	01	01	H5813_006_0	6	1	Preferred Generic	3	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					6.00	12.00	18.00																													6.00	12.00	12.00					6.00	12.00	18.00					6.00				6.00					1		
H5817	009	0	1	01	01	H5817_009_0	7	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	31	62	93							2	31	62	93							31		31	1				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	7	4	Non-Preferred Brand	1	4	100000	1	1	111100000010111000000001	31	62	93							2	31	62	93							31				31	1					53.00	25	25	25																					25	25	25																	25							25			
H5817	009	0	1	01	01	H5817_009_0	7	3	Preferred Brand	1	4	000001	1	1	111100000010111000000001	31	62	93							2	31	62	93							31				31	1					50.00	25	25	25																					25	25	25																	25							25			
H5817	009	0	1	01	01	H5817_009_0	7	5	Specialty Tier	1	4	100100	1	1	111100000010111000000111	31	62	93							2	31	62	93							31		31	1	31	1					463.00	25	25	25																					25	25	25																	25				25			25			
H5817	009	0	1	01	01	H5817_009_0	7	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	31	62	93							2	31	62	93							31		31	1				0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00					1		
H5817	009	0	1	01	01	H5817_009_0	7	2	Non-Preferred Generic	3	4	000100	1	2	011100000010111000000110	31	62	93							2	31	62	93							31		31	1				0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00					1		
H5817	009	0	1	01	01	H5817_009_0	7	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	31	62	93							2	31	62	93							31		31	1				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	8	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	31	62	93							2	31	62	93							31		31	1				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	8	5	Specialty Tier	1	4	100100	1	1	111100000010111000000111	31	62	93							2	31	62	93							31		31	1	31	1					511.00	33	33	33																					33	33	33																	33				33			33			
H5817	010	0	1	01	01	H5817_010_0	8	4	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	31	62	93							2	31	62	93							31				31	1		80.00	160.00	240.00																						80.00	120.00	160.00																		80.00								80.00				
H5817	010	0	1	01	01	H5817_010_0	8	3	Preferred Brand	1	4	000001	1	2	111100000010111000000001	31	62	93							2	31	62	93							31				31	1		40.00	80.00	120.00																						40.00	60.00	80.00																		40.00								40.00				
H5817	010	0	1	01	01	H5817_010_0	8	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	31	62	93							2	31	62	93							31		31	1				4.00	8.00	12.00																						4.00	6.00	8.00																		4.00					4.00							
H5817	010	0	1	01	01	H5817_010_0	8	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	31	62	93							2	31	62	93							31		31	1				0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00					1		
H5820	002	0	1	09	04	H5820_002_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14				6.00		18.00																						6.00	12.00	12.00																		6.00					6.00							
H5820	002	0	1	09	04	H5820_002_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14				15.00		45.00																						15.00	30.00	30.00																		15.00					15.00							
H5820	002	0	1	09	04	H5820_002_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010111000000111	31		90							1	31	60	90							31		34	14	34	14		45.00		135.00																						45.00	90.00	135.00																		45.00					45.00			45.00				
H5820	002	0	1	09	04	H5820_002_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110100000010111000000001	31		90							1	31	60	90							31				34	14		95.00		285.00																						95.00	190.00	285.00																		95.00								95.00				
H5820	002	0	1	09	04	H5820_002_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010111000000111	31		90							1	31	60	90							31		34	14	34	14					100.00	33		33																					33	33	33																	33				33			33			
H5821	013	0	1	02	01	H5821_013_0	10	1	Preferred Generic	1	4	001001	1	1	110100000001101000000111	30		90							1	30		90								15	31	15	31	14					0.00	0		0																					0		0																		0			0			0			
H5821	013	0	1	02	01	H5821_013_0	10	2	Non-Preferred Generic	1	4	000101	1	2	110100000001101000000111	30		90							1	30		90								15	31	15	31	14		3.00		9.00																						3.00		9.00																			3.00				3.00			3.00				
H5821	013	0	1	02	01	H5821_013_0	10	3	Preferred Brand	1	4	000101	3	2	110100000001101000000111	30		90							1	30		90								15	31	15	31	14		25.00		75.00																						25.00		75.00																			25.00				25.00			25.00				
H5821	013	0	1	02	01	H5821_013_0	10	4	Non-Preferred Brand	1	4	100100	1	2	110100000001101000000111	30		90							1	30		90								15	31	15	31	14		45.00		135.00																						45.00		135.00																			45.00				45.00			45.00				
H5821	013	0	1	02	01	H5821_013_0	10	5	Specialty Tier	1	4	010010	1	1	110100000001101000000111	30		90							1	30		90								15	31	15	31	14					33.00	33		33																					33		33																		33			33			33			
H5821	013	0	1	02	01	H5821_013_0	10	1	Preferred Generic	3	4	001001	1	1	110100000001101000000111	30		90							1	30		90								15	31	15	31	14					0.00	0		0																					0		0																		0			0			0	1		
H5821	013	0	1	02	01	H5821_013_0	10	2	Non-Preferred Generic	3	4	000101	1	2	110100000001101000000111	30		90							1	30		90								15	31	15	31	14		3.00		9.00																						3.00		9.00																			3.00				3.00			3.00		1		
H5821	020	0	1	01	01	H5821_020_0	10	5	Specialty Tier	1	4	010010	1	1	110100000001101000000111	30		90							1	30		90								15	31	15	31	14					33.00	33		33																					33		33																		33			33			33			
H5821	020	0	1	01	01	H5821_020_0	10	1	Preferred Generic	1	4	001001	1	1	110100000001101000000111	30		90							1	30		90								15	31	15	31	14					0.00	0		0																					0		0																		0			0			0			
H5821	020	0	1	01	01	H5821_020_0	10	4	Non-Preferred Brand	1	4	100100	1	2	110100000001101000000111	30		90							1	30		90								15	31	15	31	14		45.00		135.00																						45.00		135.00																			45.00				45.00			45.00				
H5821	020	0	1	01	01	H5821_020_0	10	3	Preferred Brand	1	4	000101	3	2	110100000001101000000111	30		90							1	30		90								15	31	15	31	14		18.00		54.00																						18.00		54.00																			18.00				18.00			18.00				
H5821	020	0	1	01	01	H5821_020_0	10	2	Non-Preferred Generic	1	4	000101	1	2	110100000001101000000111	30		90							1	30		90								15	31	15	31	14		5.00		15.00																						5.00		15.00																			5.00				5.00			5.00				
H5821	022	0	1	02	01	H5821_022_0	9	5	Specialty Tier	1	4	010010	1	1	110100000001101000000111	30		90							1	30		90								15	31	15	31	14					33.00	33		33																					33		33																		33			33			33			
H5821	022	0	1	02	01	H5821_022_0	9	3	Preferred Brand	1	4	000101	3	2	110100000001101000000111	30		90							1	30		90								15	31	15	31	14		18.00		54.00																						18.00		54.00																			18.00				18.00			18.00				
H5821	022	0	1	02	01	H5821_022_0	9	2	Non-Preferred Generic	1	4	000101	1	2	110100000001101000000111	30		90							1	30		90								15	31	15	31	14		5.00		15.00																						5.00		15.00																			5.00				5.00			5.00				
H5821	022	0	1	02	01	H5821_022_0	9	4	Non-Preferred Brand	1	4	100100	1	2	110100000001101000000111	30		90							1	30		90								15	31	15	31	14		45.00		135.00																						45.00		135.00																			45.00				45.00			45.00				
H5821	022	0	1	02	01	H5821_022_0	9	1	Preferred Generic	1	4	001001	1	1	110100000001101000000111	30		90							1	30		90								15	31	15	31	14					0.00	0		0																					0		0																		0			0			0			
H5826	008	0	1	01	01	H5826_008_0	9	3	Specialty Tier	1	4	010010	1	1	110100000010001000000101	34		90							1			90							34		34		34	14					9.08	33		33																							33																	33				33			33			
H5826	008	0	1	01	01	H5826_008_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	34		90							1			90							34		34					10.00		30.00																								30.00																		10.00					10.00							
H5826	008	0	1	01	01	H5826_008_0	9	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	34		90							1			90							34				34	14		50.00		150.00																								150.00																		50.00								50.00				
H5826	009	0	1	01	01	H5826_009_0	9	3	Specialty Tier	1	4	010010	1	1	110100000010001000000101	34		90							1			90							34		34		34	14					4.20	33		33																							33																	33				33			33			
H5826	009	0	1	01	01	H5826_009_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	34		90							1			90							34		34					10.00		30.00																								30.00																		10.00					10.00							
H5826	009	0	1	01	01	H5826_009_0	9	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	34		90							1			90							34				34	14		50.00		150.00																								150.00																		50.00								50.00				
H5826	010	0	1	01	01	H5826_010_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	34		90							1			90							34		34					10.00		30.00																								30.00																		10.00					10.00							
H5826	010	0	1	01	01	H5826_010_0	8	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	34		90							1			90							34				34	14		50.00		150.00																								150.00																		50.00								50.00				
H5826	010	0	1	01	01	H5826_010_0	8	3	Specialty Tier	1	4	010010	1	1	110100000010001000000101	34		90							1			90							34		34		34	14					5.26	33		33																							33																	33				33			33			
H5832	001	0	1	01	01	H5832_001_0	6	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					10.00	20.00	30.00																													10.00	20.00	20.00					10.00	20.00	30.00					10.00				10.00							
H5832	001	0	1	01	01	H5832_001_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H5832	001	0	1	01	01	H5832_001_0	6	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					291.04	33	33	33																												33	33	33					33	33	33				33			33			33			
H5832	001	0	1	01	01	H5832_001_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H5832	001	0	1	01	01	H5832_001_0	6	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		43.00	86.00	129.00																													43.00	86.00	86.00					43.00	86.00	129.00					43.00							43.00				
H5850	002	0	1	01	01	H5850_002_0	8	4	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					531.21	33																																										33				33			33			
H5850	002	0	1	01	01	H5850_002_0	8	3	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		76.00		228.00																						76.00		228.00																		76.00					76.00			76.00				
H5850	002	0	1	01	01	H5850_002_0	8	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		40.00		80.00																						40.00		80.00																		40.00								40.00				
H5850	002	0	1	01	01	H5850_002_0	8	1	Preferred Generic	1	4	001010	3	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00				
H5850	002	0	1	01	01	H5850_002_0	8	1	Preferred Generic	3	4	001010	3	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00		1		
H5850	003	0	1	02	01	H5850_003_0	5	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													564.09	33							564.09	33																										33				33			33			
H5850	003	0	1	02	01	H5850_003_0	5	3	Non-Preferred Brand	1	4	100100	1	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										40.00		120.00						40.00		120.00						40.00		120.00																		40.00					40.00			40.00				
H5850	003	0	1	02	01	H5850_003_0	5	2	Preferred Brand	1	4	000001	1	2	100010110110101000000001				30		90	30		90	2	30		90							30				31	14										10.00		20.00						15.00		30.00						10.00		20.00																		15.00								10.00				
H5850	003	0	1	02	01	H5850_003_0	5	1	Preferred Generic	1	4	001010	3	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										0.00		0.00						0.00		0.00						0.00		0.00																		0.00					0.00			0.00				
H5850	003	0	1	02	01	H5850_003_0	5	1	Preferred Generic	3	4	001010	3	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										5.00		10.00						5.00		10.00						5.00		10.00																		5.00					5.00			5.00		1		
H5850	004	0	1	02	01	H5850_004_0	5	1	Preferred Generic	1	4	001010	3	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										0.00		0.00						0.00		0.00						0.00		0.00																		0.00					0.00			0.00				
H5850	004	0	1	02	01	H5850_004_0	5	2	Preferred Brand	1	4	000001	1	2	100010110110101000000001				30		90	30		90	2	30		90							30				31	14										25.00		50.00						35.00		70.00						25.00		50.00																		35.00								25.00				
H5850	004	0	1	02	01	H5850_004_0	5	3	Non-Preferred Brand	1	4	100100	1	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										65.00		195.00						75.00		225.00						65.00		195.00																		75.00					65.00			65.00				
H5850	004	0	1	02	01	H5850_004_0	5	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													510.79	33							510.79	33																										33				33			33			
H5850	004	0	1	02	01	H5850_004_0	5	1	Preferred Generic	3	4	001010	3	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										5.00		10.00						5.00		10.00						5.00		10.00																		5.00					5.00			5.00		1		
H5850	005	0	1	02	01	H5850_005_0	5	1	Preferred Generic	1	4	001010	3	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										3.00		6.00						3.00		6.00						3.00		6.00																		3.00					3.00			3.00				
H5850	005	0	1	02	01	H5850_005_0	5	2	Preferred Brand	1	4	000001	1	2	100010110110101000000001				30		90	30		90	2	30		90							30				31	14										30.00		60.00						40.00		80.00						30.00		60.00																		40.00								30.00				
H5850	005	0	1	02	01	H5850_005_0	5	3	Non-Preferred Brand	1	4	100100	1	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										70.00		210.00						89.00		267.00						70.00		210.00																		89.00					70.00			70.00				
H5850	005	0	1	02	01	H5850_005_0	5	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													739.95	33							739.95	33																										33				33			33			
H5850	006	0	1	01	01	H5850_006_0	6	1	Preferred Generic	1	4	001010	3	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										0.00		0.00						0.00		0.00						0.00		0.00																		0.00					0.00			0.00				
H5850	006	0	1	01	01	H5850_006_0	6	2	Preferred Brand	1	4	000001	1	2	100010110110101000000001				30		90	30		90	2	30		90							30				31	14										0.00		0.00						0.00		0.00						0.00		0.00																		0.00								0.00				
H5850	006	0	1	01	01	H5850_006_0	6	3	Non-Preferred Brand	1	4	100100	1	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										50.00		150.00						60.00		180.00						50.00		150.00																		60.00					50.00			50.00				
H5850	006	0	1	01	01	H5850_006_0	6	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													920.88	33							920.88	33																										33				33			33			
H5850	006	0	1	01	01	H5850_006_0	6	1	Preferred Generic	3	4	001010	3	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										0.00		0.00						0.00		0.00						0.00		0.00																		0.00					0.00			0.00		1		
H5850	007	0	1	02	01	H5850_007_0	5	3	Non-Preferred Brand	1	4	100100	1	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										60.00		180.00						60.00		180.00						60.00		180.00																		60.00					60.00			60.00				
H5850	007	0	1	02	01	H5850_007_0	5	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													758.48	33							758.48	33																										33				33			33			
H5850	007	0	1	02	01	H5850_007_0	5	1	Preferred Generic	3	4	001010	3	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										3.00		6.00						3.00		6.00						3.00		6.00																		3.00					3.00			3.00		1		
H5850	007	0	1	02	01	H5850_007_0	5	2	Preferred Brand	1	4	000001	1	2	100010110110101000000001				30		90	30		90	2	30		90							30				31	14										25.00		50.00						30.00		60.00						25.00		50.00																		30.00								25.00				
H5850	007	0	1	02	01	H5850_007_0	5	1	Preferred Generic	1	4	001010	3	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										0.00		0.00						0.00		0.00						0.00		0.00																		0.00					0.00			0.00				
H5850	012	0	1	02	01	H5850_012_0	5	1	Preferred Generic	1	4	001010	3	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										0.00		0.00						0.00		0.00						0.00		0.00																		0.00					0.00			0.00				
H5850	012	0	1	02	01	H5850_012_0	5	3	Non-Preferred Brand	1	4	100100	1	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										25.00		75.00						30.00		90.00						25.00		75.00																		30.00					25.00			25.00				
H5850	012	0	1	02	01	H5850_012_0	5	1	Preferred Generic	3	4	001010	3	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										0.00		0.00						0.00		0.00						0.00		0.00																		0.00					0.00			0.00		1		
H5850	012	0	1	02	01	H5850_012_0	5	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													654.86	33							654.86	33																										33				33			33			
H5850	012	0	1	02	01	H5850_012_0	5	2	Preferred Brand	1	4	000001	1	2	100010110110101000000001				30		90	30		90	2	30		90							30				31	14										0.00		0.00						0.00		0.00						0.00		0.00																		0.00								0.00				
H5850	021	0	1	01	01	H5850_021_0	5	4	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					600.94	33																																										33				33			33			
H5850	021	0	1	01	01	H5850_021_0	5	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		45.00		90.00																						45.00		90.00																		45.00								45.00				
H5850	021	0	1	01	01	H5850_021_0	5	3	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		76.00		228.00																						76.00		228.00																		76.00					76.00			76.00				
H5850	021	0	1	01	01	H5850_021_0	5	1	Preferred Generic	1	4	001010	3	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00				
H5850	022	0	1	01	01	H5850_022_0	5	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													369.48	33							369.48	33																										33				33			33			
H5850	022	0	1	01	01	H5850_022_0	5	1	Preferred Generic	1	4	001010	3	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										0.00		0.00						0.00		0.00						0.00		0.00																		0.00					0.00			0.00				
H5850	022	0	1	01	01	H5850_022_0	5	3	Non-Preferred Brand	1	4	100100	1	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										70.00		210.00						89.00		267.00						70.00		210.00																		89.00					70.00			70.00				
H5850	022	0	1	01	01	H5850_022_0	5	2	Preferred Brand	1	4	000001	1	2	100010110110101000000001				30		90	30		90	2	30		90							30				31	14										35.00		70.00						45.00		90.00						35.00		70.00																		45.00								35.00				
H5850	022	0	1	01	01	H5850_022_0	5	1	Preferred Generic	3	4	001010	3	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										5.00		10.00						5.00		10.00						5.00		10.00																		5.00					5.00			5.00		1		
H5850	023	0	1	01	01	H5850_023_0	5	4	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					531.92	33																																										33				33			33			
H5850	023	0	1	01	01	H5850_023_0	5	1	Preferred Generic	3	4	001010	3	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00		1		
H5850	023	0	1	01	01	H5850_023_0	5	1	Preferred Generic	1	4	001010	3	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00				
H5850	023	0	1	01	01	H5850_023_0	5	3	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		76.00		228.00																						76.00		228.00																		76.00					76.00			76.00				
H5850	023	0	1	01	01	H5850_023_0	5	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		45.00		90.00																						45.00		90.00																		45.00								45.00				
H5850	024	0	1	02	01	H5850_024_0	5	1	Preferred Generic	3	4	001010	3	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		5.00		10.00																						5.00		10.00																		5.00					5.00			5.00		1		
H5850	024	0	1	02	01	H5850_024_0	5	3	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		70.00		210.00																						70.00		210.00																		70.00					70.00			70.00				
H5850	024	0	1	02	01	H5850_024_0	5	4	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					574.85	33																																										33				33			33			
H5850	024	0	1	02	01	H5850_024_0	5	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		30.00		60.00																						30.00		60.00																		30.00								30.00				
H5850	024	0	1	02	01	H5850_024_0	5	1	Preferred Generic	1	4	001010	3	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00				
H5850	025	0	1	01	01	H5850_025_0	5	2	Preferred Brand	1	4	000001	1	2	100010110110101000000001				30		90	30		90	2	30		90							30				31	14										20.00		40.00						25.00		50.00						20.00		40.00																		25.00								20.00				
H5850	025	0	1	01	01	H5850_025_0	5	1	Preferred Generic	1	4	001010	3	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										0.00		0.00						0.00		0.00						0.00		0.00																		0.00					0.00			0.00				
H5850	025	0	1	01	01	H5850_025_0	5	3	Non-Preferred Brand	1	4	100100	1	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										60.00		180.00						60.00		180.00						60.00		180.00																		60.00					60.00			60.00				
H5850	025	0	1	01	01	H5850_025_0	5	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													574.82	33							574.82	33																										33				33			33			
H5850	025	0	1	01	01	H5850_025_0	5	1	Preferred Generic	3	4	001010	3	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										3.00		6.00						3.00		6.00						3.00		6.00																		3.00					3.00			3.00		1		
H5850	026	0	1	02	01	H5850_026_0	6	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													961.01	33							961.01	33																										33				33			33			
H5850	026	0	1	02	01	H5850_026_0	6	3	Non-Preferred Brand	1	4	100100	1	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										70.00		210.00						79.00		237.00						70.00		210.00																		79.00					70.00			70.00				
H5850	026	0	1	02	01	H5850_026_0	6	2	Preferred Brand	1	4	000001	1	2	100010110110101000000001				30		90	30		90	2	30		90							30				31	14										30.00		60.00						39.00		78.00						30.00		60.00																		39.00								30.00				
H5850	026	0	1	02	01	H5850_026_0	6	1	Preferred Generic	1	4	001010	3	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										0.00		0.00						0.00		0.00						0.00		0.00																		0.00					0.00			0.00				
H5850	026	0	1	02	01	H5850_026_0	6	1	Preferred Generic	3	4	001010	3	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										5.00		10.00						5.00		10.00						5.00		10.00																		5.00					5.00			5.00		1		
H5852	001	0	1	01	01	H5852_001_0	7	2	Preferred Brand	1	2	010001		1	110100000010000000000111	30		90							1										30		34	14	34	14					2000.00	25		25																																								25				25			25			
H5852	001	0	1	01	01	H5852_001_0	7	1	Preferred Generic	1	2	001010		1	110100000010000000000111	30		90							1										30		34	14	34	14					2000.00	25		25																																								25				25			25			
H5852	001	0	1	01	01	H5852_001_0	7	3	Non-Preferred Brand	1	2	100000		1	110000000010000000000001	30																			30				34	14					2000.00	25																																										25							25			
H5854	005	0	1	01	01	H5854_005_0	11	5	Injectable Drugs	1	3	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					91.00	33	33	33																					33	33	33																	33				33			33			
H5854	005	0	1	01	01	H5854_005_0	11	6	Specialty Tier	1	3	010010		1	110000000010100000000111	30										30									30		34	14	34	14					630.00	33																							33																			33				33			33			
H5854	005	0	1	01	01	H5854_005_0	11	3	Preferred Brand	1	3	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		37.00	74.00	111.00																						37.00	74.00	92.50																		37.00					37.00			37.00				
H5854	005	0	1	01	01	H5854_005_0	11	2	Non-Preferred Generic	1	3	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				10.00	20.00	30.00																						10.00	20.00	15.00																		10.00					10.00							
H5854	005	0	1	01	01	H5854_005_0	11	1	Preferred Generic	1	3	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				6.00	12.00	18.00																						6.00	12.00	9.00																		6.00					6.00							
H5854	005	0	1	01	01	H5854_005_0	11	4	Non-Preferred Brand	1	3	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		80.00	160.00	240.00																						80.00	160.00	200.00																		80.00					80.00			80.00				
H5859	003	0	1	02	01	H5859_003_0	5	2	Brand	1	4	000010	1	1	110100000010101000000001	34		90							1	34		90							34				34	14					24.82	25		25																					25		25																	25							25			
H5859	003	0	1	02	01	H5859_003_0	5	1	Generic	1	4	010000	1	2	010100000010101000000100	34		90							1	34		90							34		34					5.00		15.00																						5.00		15.00																		5.00					5.00							
H5868	001	0	1	04	01	H5868_001_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H5868	001	0	1	04	01	H5868_001_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H5868	001	0	1	04	01	H5868_001_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H5868	001	0	1	04	01	H5868_001_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H5868	001	0	1	04	01	H5868_001_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1027.00	33																														33							33					33				33			33	2	3	
H5868	001	0	1	04	01	H5868_001_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00		2	3	1
H5868	001	0	1	04	01	H5868_001_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H5868	001	0	1	04	01	H5868_001_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H5868	001	0	1	04	01	H5868_001_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H5868	001	0	1	04	01	H5868_001_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					876.00	33																														33							33					33				33			33			
H5883	002	1	1	02	01	H5883_002_1	11	4	Non-Preferred Brand	1	4	100000	1	2	100010110110101000000001				34		90	34		90	1	34		90							34				34	14										80.00		200.00						80.00		240.00						80.00		200.00																		80.00								80.00				
H5883	002	1	1	02	01	H5883_002_1	11	3	Preferred Brand	1	4	000001	1	2	100010110110101000000001				34		90	34		90	1	34		90							34				34	14										40.00		100.00						40.00		120.00						40.00		100.00																		40.00								40.00				
H5883	002	1	1	02	01	H5883_002_1	11	2	Non-Preferred Generic	1	4	000100	1	2	000010110110101000000100				34		90	34		90	1	34		90							34		34													10.00		25.00						10.00		30.00						10.00		25.00																		10.00					10.00							
H5883	002	1	1	02	01	H5883_002_1	11	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				34		90	34		90	1	34		90							34		34													3.00		7.50						3.00		9.00						3.00		7.50																		3.00					3.00							
H5883	002	1	1	02	01	H5883_002_1	11	2	Non-Preferred Generic	3	4	000100	1	1	000010110110101000000100				34		90	34		90	1	34		90							34		34																19.00	50		45					19.00	50		50					50		45																	50				50				1		
H5883	002	1	1	02	01	H5883_002_1	11	1	Preferred Generic	3	4	001000	1	1	000010110110101000000100				34		90	34		90	1	34		90							34		34																8.00	50		45					8.00	50		50					50		45																	50				50				1		
H5883	002	1	1	02	01	H5883_002_1	11	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				34			34				34									34		34		34	14													381.00	30							381.00	30							30																			30				30			30			
H5883	002	2	1	02	01	H5883_002_2	11	3	Preferred Brand	1	4	000001	1	2	100010110110101000000001				34		90	34		90	1	34		90							34				34	14										40.00		100.00						40.00		120.00						40.00		100.00																		40.00								40.00				
H5883	002	2	1	02	01	H5883_002_2	11	4	Non-Preferred Brand	1	4	100000	1	2	100010110110101000000001				34		90	34		90	1	34		90							34				34	14										80.00		200.00						80.00		240.00						80.00		200.00																		80.00								80.00				
H5883	002	2	1	02	01	H5883_002_2	11	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				34			34				34									34		34		34	14													381.00	30							381.00	30							30																			30				30			30			
H5883	002	2	1	02	01	H5883_002_2	11	2	Non-Preferred Generic	3	4	000100	1	1	000010110110101000000100				34		90	34		90	1	34		90							34		34																19.00	50		45					19.00	50		50					50		45																	50				50				1		
H5883	002	2	1	02	01	H5883_002_2	11	1	Preferred Generic	3	4	001000	1	1	000010110110101000000100				34		90	34		90	1	34		90							34		34																8.00	50		45					8.00	50		50					50		45																	50				50				1		
H5883	002	2	1	02	01	H5883_002_2	11	2	Non-Preferred Generic	1	4	000100	1	2	000010110110101000000100				34		90	34		90	1	34		90							34		34													10.00		25.00						10.00		30.00						10.00		25.00																		10.00					10.00							
H5883	002	2	1	02	01	H5883_002_2	11	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				34		90	34		90	1	34		90							34		34													3.00		7.50						3.00		9.00						3.00		7.50																		3.00					3.00							
H5883	002	3	1	02	01	H5883_002_3	11	2	Non-Preferred Generic	3	4	000100	1	1	000010110110101000000100				34		90	34		90	1	34		90							34		34																19.00	50		45					19.00	50		50					50		45																	50				50				1		
H5883	002	3	1	02	01	H5883_002_3	11	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				34		90	34		90	1	34		90							34		34													3.00		7.50						3.00		9.00						3.00		7.50																		3.00					3.00							
H5883	002	3	1	02	01	H5883_002_3	11	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				34			34				34									34		34		34	14													381.00	30							381.00	30							30																			30				30			30			
H5883	002	3	1	02	01	H5883_002_3	11	1	Preferred Generic	3	4	001000	1	1	000010110110101000000100				34		90	34		90	1	34		90							34		34																8.00	50		45					8.00	50		50					50		45																	50				50				1		
H5883	002	3	1	02	01	H5883_002_3	11	2	Non-Preferred Generic	1	4	000100	1	2	000010110110101000000100				34		90	34		90	1	34		90							34		34													10.00		25.00						10.00		30.00						10.00		25.00																		10.00					10.00							
H5883	002	3	1	02	01	H5883_002_3	11	4	Non-Preferred Brand	1	4	100000	1	2	100010110110101000000001				34		90	34		90	1	34		90							34				34	14										80.00		200.00						80.00		240.00						80.00		200.00																		80.00								80.00				
H5883	002	3	1	02	01	H5883_002_3	11	3	Preferred Brand	1	4	000001	1	2	100010110110101000000001				34		90	34		90	1	34		90							34				34	14										40.00		100.00						40.00		120.00						40.00		100.00																		40.00								40.00				
H5883	002	4	1	02	01	H5883_002_4	11	1	Preferred Generic	3	4	001000	1	1	000010110110101000000100				34		90	34		90	1	34		90							34		34																8.00	50		45					8.00	50		50					50		45																	50				50				1		
H5883	002	4	1	02	01	H5883_002_4	11	2	Non-Preferred Generic	3	4	000100	1	1	000010110110101000000100				34		90	34		90	1	34		90							34		34																19.00	50		45					19.00	50		50					50		45																	50				50				1		
H5883	002	4	1	02	01	H5883_002_4	11	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				34			34				34									34		34		34	14													381.00	30							381.00	30							30																			30				30			30			
H5883	002	4	1	02	01	H5883_002_4	11	4	Non-Preferred Brand	1	4	100000	1	2	100010110110101000000001				34		90	34		90	1	34		90							34				34	14										80.00		200.00						80.00		240.00						80.00		200.00																		80.00								80.00				
H5883	002	4	1	02	01	H5883_002_4	11	3	Preferred Brand	1	4	000001	1	2	100010110110101000000001				34		90	34		90	1	34		90							34				34	14										40.00		100.00						40.00		120.00						40.00		100.00																		40.00								40.00				
H5883	002	4	1	02	01	H5883_002_4	11	2	Non-Preferred Generic	1	4	000100	1	2	000010110110101000000100				34		90	34		90	1	34		90							34		34													10.00		25.00						10.00		30.00						10.00		25.00																		10.00					10.00							
H5883	002	4	1	02	01	H5883_002_4	11	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				34		90	34		90	1	34		90							34		34													3.00		7.50						3.00		9.00						3.00		7.50																		3.00					3.00							
H5883	002	7	1	02	01	H5883_002_7	11	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				34		90	34		90	1	34		90							34		34													3.00		7.50						3.00		9.00						3.00		7.50																		3.00					3.00							
H5883	002	7	1	02	01	H5883_002_7	11	2	Non-Preferred Generic	1	4	000100	1	2	000010110110101000000100				34		90	34		90	1	34		90							34		34													10.00		25.00						10.00		30.00						10.00		25.00																		10.00					10.00							
H5883	002	7	1	02	01	H5883_002_7	11	3	Preferred Brand	1	4	000001	1	2	100010110110101000000001				34		90	34		90	1	34		90							34				34	14										40.00		100.00						40.00		120.00						40.00		100.00																		40.00								40.00				
H5883	002	7	1	02	01	H5883_002_7	11	4	Non-Preferred Brand	1	4	100000	1	2	100010110110101000000001				34		90	34		90	1	34		90							34				34	14										80.00		200.00						80.00		240.00						80.00		200.00																		80.00								80.00				
H5883	002	7	1	02	01	H5883_002_7	11	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				34			34				34									34		34		34	14													381.00	30							381.00	30							30																			30				30			30			
H5883	002	7	1	02	01	H5883_002_7	11	1	Preferred Generic	3	4	001000	1	1	000010110110101000000100				34		90	34		90	1	34		90							34		34																8.00	50		45					8.00	50		50					50		45																	50				50				1		
H5883	002	7	1	02	01	H5883_002_7	11	2	Non-Preferred Generic	3	4	000100	1	1	000010110110101000000100				34		90	34		90	1	34		90							34		34																19.00	50		45					19.00	50		50					50		45																	50				50				1		
H5883	003	1	1	02	01	H5883_003_1	12	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				34		90	34		90	1	34		90							34		34													3.00		7.50						3.00		9.00						3.00		7.50																		3.00					3.00							
H5883	003	1	1	02	01	H5883_003_1	12	2	Non-Preferred Generic	1	4	000100	1	2	000010110110101000000100				34		90	34		90	1	34		90							34		34													10.00		25.00						10.00		30.00						10.00		25.00																		10.00					10.00							
H5883	003	1	1	02	01	H5883_003_1	12	3	Preferred Brand	1	4	000001	1	2	100010110110101000000001				34		90	34		90	1	34		90							34				34	14										35.00		87.50						35.00		105.00						35.00		87.50																		35.00								35.00				
H5883	003	1	1	02	01	H5883_003_1	12	4	Non-Preferred Brand	1	4	100000	1	2	100010110110101000000001				34		90	34		90	1	34		90							34				34	14										75.00		187.50						75.00		225.00						75.00		187.50																		75.00								75.00				
H5883	003	1	1	02	01	H5883_003_1	12	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				34			34				34									34		34		34	14													444.00	30							444.00	30							30																			30				30			30			
H5883	003	1	1	02	01	H5883_003_1	12	1	Preferred Generic	3	4	001000	1	2	000010110110101000000100				34		90	34		90	1	34		90							34		34													5.00		12.50						5.00		15.00						5.00		12.50																		5.00					5.00					1		
H5883	003	1	1	02	01	H5883_003_1	12	2	Non-Preferred Generic	3	4	000100	1	2	000010110110101000000100				34		90	34		90	1	34		90							34		34													12.00		30.00						12.00		36.00						12.00		30.00																		12.00					12.00					1		
H5883	003	2	1	02	01	H5883_003_2	12	3	Preferred Brand	1	4	000001	1	2	100010110110101000000001				34		90	34		90	1	34		90							34				34	14										35.00		87.50						35.00		105.00						35.00		87.50																		35.00								35.00				
H5883	003	2	1	02	01	H5883_003_2	12	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				34		90	34		90	1	34		90							34		34													3.00		7.50						3.00		9.00						3.00		7.50																		3.00					3.00							
H5883	003	2	1	02	01	H5883_003_2	12	2	Non-Preferred Generic	1	4	000100	1	2	000010110110101000000100				34		90	34		90	1	34		90							34		34													10.00		25.00						10.00		30.00						10.00		25.00																		10.00					10.00							
H5883	003	2	1	02	01	H5883_003_2	12	4	Non-Preferred Brand	1	4	100000	1	2	100010110110101000000001				34		90	34		90	1	34		90							34				34	14										75.00		187.50						75.00		225.00						75.00		187.50																		75.00								75.00				
H5883	003	2	1	02	01	H5883_003_2	12	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				34			34				34									34		34		34	14													444.00	30							444.00	30							30																			30				30			30			
H5883	003	2	1	02	01	H5883_003_2	12	1	Preferred Generic	3	4	001000	1	2	000010110110101000000100				34		90	34		90	1	34		90							34		34													5.00		12.50						5.00		15.00						5.00		12.50																		5.00					5.00					1		
H5883	003	2	1	02	01	H5883_003_2	12	2	Non-Preferred Generic	3	4	000100	1	2	000010110110101000000100				34		90	34		90	1	34		90							34		34													12.00		30.00						12.00		36.00						12.00		30.00																		12.00					12.00					1		
H5883	003	3	1	02	01	H5883_003_3	12	3	Preferred Brand	1	4	000001	1	2	100010110110101000000001				34		90	34		90	1	34		90							34				34	14										35.00		87.50						35.00		105.00						35.00		87.50																		35.00								35.00				
H5883	003	3	1	02	01	H5883_003_3	12	1	Preferred Generic	3	4	001000	1	2	000010110110101000000100				34		90	34		90	1	34		90							34		34													5.00		12.50						5.00		15.00						5.00		12.50																		5.00					5.00					1		
H5883	003	3	1	02	01	H5883_003_3	12	2	Non-Preferred Generic	3	4	000100	1	2	000010110110101000000100				34		90	34		90	1	34		90							34		34													12.00		30.00						12.00		36.00						12.00		30.00																		12.00					12.00					1		
H5883	003	3	1	02	01	H5883_003_3	12	4	Non-Preferred Brand	1	4	100000	1	2	100010110110101000000001				34		90	34		90	1	34		90							34				34	14										75.00		187.50						75.00		225.00						75.00		187.50																		75.00								75.00				
H5883	003	3	1	02	01	H5883_003_3	12	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				34			34				34									34		34		34	14													444.00	30							444.00	30							30																			30				30			30			
H5883	003	3	1	02	01	H5883_003_3	12	2	Non-Preferred Generic	1	4	000100	1	2	000010110110101000000100				34		90	34		90	1	34		90							34		34													10.00		25.00						10.00		30.00						10.00		25.00																		10.00					10.00							
H5883	003	3	1	02	01	H5883_003_3	12	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				34		90	34		90	1	34		90							34		34													3.00		7.50						3.00		9.00						3.00		7.50																		3.00					3.00							
H5883	003	4	1	02	01	H5883_003_4	12	3	Preferred Brand	1	4	000001	1	2	100010110110101000000001				34		90	34		90	1	34		90							34				34	14										35.00		87.50						35.00		105.00						35.00		87.50																		35.00								35.00				
H5883	003	4	1	02	01	H5883_003_4	12	2	Non-Preferred Generic	3	4	000100	1	2	000010110110101000000100				34		90	34		90	1	34		90							34		34													12.00		30.00						12.00		36.00						12.00		30.00																		12.00					12.00					1		
H5883	003	4	1	02	01	H5883_003_4	12	1	Preferred Generic	3	4	001000	1	2	000010110110101000000100				34		90	34		90	1	34		90							34		34													5.00		12.50						5.00		15.00						5.00		12.50																		5.00					5.00					1		
H5883	003	4	1	02	01	H5883_003_4	12	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				34			34				34									34		34		34	14													444.00	30							444.00	30							30																			30				30			30			
H5883	003	4	1	02	01	H5883_003_4	12	4	Non-Preferred Brand	1	4	100000	1	2	100010110110101000000001				34		90	34		90	1	34		90							34				34	14										75.00		187.50						75.00		225.00						75.00		187.50																		75.00								75.00				
H5883	003	4	1	02	01	H5883_003_4	12	2	Non-Preferred Generic	1	4	000100	1	2	000010110110101000000100				34		90	34		90	1	34		90							34		34													10.00		25.00						10.00		30.00						10.00		25.00																		10.00					10.00							
H5883	003	4	1	02	01	H5883_003_4	12	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				34		90	34		90	1	34		90							34		34													3.00		7.50						3.00		9.00						3.00		7.50																		3.00					3.00							
H5883	003	5	1	02	01	H5883_003_5	13	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				34			34				34									34		34		34	14													444.00	30							444.00	30							30																			30				30			30			
H5883	003	5	1	02	01	H5883_003_5	13	1	Preferred Generic	3	4	001000	1	2	000010110110101000000100				34		90	34		90	1	34		90							34		34													5.00		12.50						5.00		15.00						5.00		12.50																		5.00					5.00					1		
H5883	003	5	1	02	01	H5883_003_5	13	2	Non-Preferred Generic	3	4	000100	1	2	000010110110101000000100				34		90	34		90	1	34		90							34		34													12.00		30.00						12.00		36.00						12.00		30.00																		12.00					12.00					1		
H5883	003	5	1	02	01	H5883_003_5	13	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				34		90	34		90	1	34		90							34		34													3.00		7.50						3.00		9.00						3.00		7.50																		3.00					3.00							
H5883	003	5	1	02	01	H5883_003_5	13	2	Non-Preferred Generic	1	4	000100	1	2	000010110110101000000100				34		90	34		90	1	34		90							34		34													10.00		25.00						10.00		30.00						10.00		25.00																		10.00					10.00							
H5883	003	5	1	02	01	H5883_003_5	13	4	Non-Preferred Brand	1	4	100000	1	2	100010110110101000000001				34		90	34		90	1	34		90							34				34	14										75.00		187.50						75.00		225.00						75.00		187.50																		75.00								75.00				
H5883	003	5	1	02	01	H5883_003_5	13	3	Preferred Brand	1	4	000001	1	2	100010110110101000000001				34		90	34		90	1	34		90							34				34	14										35.00		87.50						35.00		105.00						35.00		87.50																		35.00								35.00				
H5883	005	0	1	01	01	H5883_005_0	11	3	Preferred Brand	1	4	000001	1	2	100010110110101000000001				34		90	34		90	1	34		90							34				34	14										45.00		112.50						45.00		135.00						45.00		112.50																		45.00								45.00				
H5883	005	0	1	01	01	H5883_005_0	11	4	Non-Preferred Brand	1	4	100000	1	2	100010110110101000000001				34		90	34		90	1	34		90							34				34	14										80.00		200.00						80.00		240.00						80.00		200.00																		80.00								80.00				
H5883	005	0	1	01	01	H5883_005_0	11	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				34			34				34									34		34		34	14													380.00	30							380.00	30							30																			30				30			30			
H5883	005	0	1	01	01	H5883_005_0	11	2	Non-Preferred Generic	1	4	000100	1	2	000010110110101000000100				34		90	34		90	1	34		90							34		34													10.00		25.00						10.00		30.00						10.00		25.00																		10.00					10.00							
H5883	005	0	1	01	01	H5883_005_0	11	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				34		90	34		90	1	34		90							34		34													4.00		10.00						4.00		12.00						4.00		10.00																		4.00					4.00							
H5887	001	0	1	01	01	H5887_001_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010000000000110	30		90							2										30		31	14				5.00		15.00																																										5.00					5.00							
H5887	001	0	1	01	01	H5887_001_0	8	1	Preferred Generic	3	4	001000	1	2	010100000010000000000110	30		90							2										30		31	14				5.00		15.00																																										5.00					5.00					1		
H5887	001	0	1	01	01	H5887_001_0	8	2	Preferred Brand	1	4	000001	1	2	110100000010000000000001	30		90							2										30				31	14		25.00		75.00																																										25.00								25.00				
H5887	001	0	1	01	01	H5887_001_0	8	3	Non-Preferred Brand	1	4	100000	1	2	110100000010000000000001	30		90							2										30				31	14		45.00		135.00																																										45.00								45.00				
H5887	001	0	1	01	01	H5887_001_0	8	4	Specialty Tier	1	4	000010	1	1	110100000010000000000001	30		90							2										30				31	14					457.00	25		25																																								25							25			
H5887	007	0	1	01	01	H5887_007_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010000000000110	30		90							2										30		31	14				4.00		12.00																																										4.00					4.00							
H5887	007	0	1	01	01	H5887_007_0	8	2	Preferred Brand	1	4	000001	1	2	110100000010000000000001	30		90							2										30				31	14		20.00		60.00																																										20.00								20.00				
H5887	007	0	1	01	01	H5887_007_0	8	4	Specialty Tier	1	4	000010	1	1	110100000010000000000001	30		90							2										30				31	14					238.00	25		25																																								25							25			
H5887	007	0	1	01	01	H5887_007_0	8	3	Non-Preferred Brand	1	4	100000	1	2	110100000010000000000001	30		90							2										30				31	14		40.00		120.00																																										40.00								40.00				
H5887	007	0	1	01	01	H5887_007_0	8	1	Preferred Generic	3	4	001000	1	2	010100000010000000000110	30		90							2										30		31	14				4.00		12.00																																										4.00					4.00					1		
H5887	011	0	1	01	01	H5887_011_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010000000000110	30		90							2										30		31	14				5.00		15.00																																										5.00					5.00							
H5887	011	0	1	01	01	H5887_011_0	8	3	Non-Preferred Brand	1	4	100000	1	2	110100000010000000000001	30		90							2										30				31	14		50.00		150.00																																										50.00								50.00				
H5887	011	0	1	01	01	H5887_011_0	8	4	Specialty Tier	1	4	000010	1	1	110100000010000000000001	30		90							2										30				31	14					461.00	25		25																																								25							25			
H5887	011	0	1	01	01	H5887_011_0	8	1	Preferred Generic	3	4	001000	1	2	010100000010000000000110	30		90							2										30		31	14				5.00		15.00																																										5.00					5.00					1		
H5887	011	0	1	01	01	H5887_011_0	8	2	Preferred Brand	1	4	000001	1	2	110100000010000000000001	30		90							2										30				31	14		30.00		90.00																																										30.00								30.00				
H5887	012	0	1	01	01	H5887_012_0	9	2	Preferred Brand	1	4	000001	1	2	110100000010000000000001	30		90							2										30				31	14		30.00		90.00																																										30.00								30.00				
H5887	012	0	1	01	01	H5887_012_0	9	3	Non-Preferred Brand	1	4	100000	1	2	110100000010000000000001	30		90							2										30				31	14		50.00		150.00																																										50.00								50.00				
H5887	012	0	1	01	01	H5887_012_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010000000000110	30		90							2										30		31	14				5.00		15.00																																										5.00					5.00							
H5887	012	0	1	01	01	H5887_012_0	9	4	Specialty Tier	1	4	000010	1	1	110100000010000000000001	30		90							2										30				31	14					464.00	25		25																																								25							25			
H5887	012	0	1	01	01	H5887_012_0	9	1	Preferred Generic	3	4	001000	1	2	010100000010000000000110	30		90							2										30		31	14				5.00		15.00																																										5.00					5.00					1		
H5896	007	0	1	01	01	H5896_007_0	8	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	31	62	93							2	31	62	93							31		31	1				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	8	2	Non-Preferred Generic	1	4	000100	1	1	011100000010111000000110	31	62	93							2	31	62	93							31		31	1							7.00	25	25	25																					25	25	25																	25				25						
H5896	007	0	1	01	01	H5896_007_0	8	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	31	62	93							2	31	62	93							31		31	1				0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00					1		
H5896	007	0	1	01	01	H5896_007_0	8	4	Non-Preferred Brand	1	4	100000	1	1	111100000010111000000001	31	62	93							2	31	62	93							31				31	1					61.00	25	25	25																					25	25	25																	25							25			
H5896	007	0	1	01	01	H5896_007_0	8	5	Specialty Tier	1	4	100100	1	1	111100000010111000000111	31	62	93							2	31	62	93							31		31	1	31	1					543.00	25	25	25																					25	25	25																	25				25			25			
H5896	007	0	1	01	01	H5896_007_0	8	3	Preferred Brand	1	4	000001	1	1	111100000010111000000001	31	62	93							2	31	62	93							31				31	1					48.00	25	25	25																					25	25	25																	25							25			
H5926	001	0	1	01	01	H5926_001_0	7	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	31	60	90							1	31	60	90							31				31	14		45.00	90.00	135.00																						45.00	90.00	135.00																		45.00								45.00				
H5926	001	0	1	01	01	H5926_001_0	7	1	Generic	1	4	010000	1	2	011100000010111000000110	31	60	90							1	31	60	90							31		31	14				0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00							
H5926	001	0	1	01	01	H5926_001_0	7	4	Specialty Tier	1	4	010010	1	1	110000000010100000000111	31										31									31		31	14	31	14					531.24	25																							25																			25				25			25			
H5926	001	0	1	01	01	H5926_001_0	7	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	31	60	90							1	31	60	90							31				31	14		95.00	190.00	285.00																						95.00	190.00	285.00																		95.00								95.00				
H5928	001	0	1	01	01	H5928_001_0	11	3	Preferred Brand	1	4	000001	1	1	110100000010001000000001	30		90							2			90							30				31	14					43.81	25		25																							25																	25							25			
H5928	001	0	1	01	01	H5928_001_0	11	4	Non-Preferred Brand	1	4	100100	1	1	110100000010001000000111	30		90							2			90							30		31	14	31	14					39.16	25		25																							25																	25				25			25			
H5928	001	0	1	01	01	H5928_001_0	11	5	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							2			90							30		31	14	31	14					261.00	25		25																							25																	25				25			25			
H5928	001	0	1	01	01	H5928_001_0	11	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H5928	001	0	1	01	01	H5928_001_0	11	2	Non-Preferred Generic	1	4	000100	1	1	010100000010001000000110	30		90							2			90							30		31	14							4.30	25		25																							25																	25				25						
H5928	001	0	1	01	01	H5928_001_0	11	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5928	004	0	1	01	01	H5928_004_0	10	5	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							2			90							30		31	14	31	14					532.73	30		30																							30																	30				30			30			
H5928	004	0	1	01	01	H5928_004_0	10	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				5.00		10.00																								10.00																		5.00					5.00					1		
H5928	004	0	1	01	01	H5928_004_0	10	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H5928	004	0	1	01	01	H5928_004_0	10	4	Non-Preferred Brand	1	4	100100	1	2	110100000010001000000111	30		90							2			90							30		31	14	31	14		50.00		100.00																								100.00																		50.00					50.00			50.00				
H5928	004	0	1	01	01	H5928_004_0	10	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		30.00		60.00																								60.00																		30.00								30.00				
H5928	004	0	1	01	01	H5928_004_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				5.00		10.00																								10.00																		5.00					5.00							
H5928	004	0	1	01	01	H5928_004_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5928	005	0	1	01	01	H5928_005_0	10	2	Non-Preferred Generic	1	4	000100	1	1	010100000010001000000110	30		90							2			90							30		31	14							4.30	25		25																							25																	25				25						
H5928	005	0	1	01	01	H5928_005_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5928	005	0	1	01	01	H5928_005_0	10	3	Preferred Brand	1	4	000001	1	1	110100000010001000000001	30		90							2			90							30				31	14					43.81	25		25																							25																	25							25			
H5928	005	0	1	01	01	H5928_005_0	10	4	Non-Preferred Brand	1	4	100100	1	1	110100000010001000000111	30		90							2			90							30		31	14	31	14					39.16	25		25																							25																	25				25			25			
H5928	005	0	1	01	01	H5928_005_0	10	5	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							2			90							30		31	14	31	14					261.00	25		25																							25																	25				25			25			
H5928	005	0	1	01	01	H5928_005_0	10	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H5928	006	0	1	01	01	H5928_006_0	11	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5928	006	0	1	01	01	H5928_006_0	11	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		30.00		60.00																								60.00																		30.00								30.00				
H5928	006	0	1	01	01	H5928_006_0	11	4	Non-Preferred Brand	1	4	100100	1	2	110100000010001000000111	30		90							2			90							30		31	14	31	14		50.00		100.00																								100.00																		50.00					50.00			50.00				
H5928	006	0	1	01	01	H5928_006_0	11	5	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							2			90							30		31	14	31	14					532.73	30		30																							30																	30				30			30			
H5928	006	0	1	01	01	H5928_006_0	11	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				5.00		10.00																								10.00																		5.00					5.00							
H5928	006	0	1	01	01	H5928_006_0	11	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				5.00		10.00																								10.00																		5.00					5.00					1		
H5928	006	0	1	01	01	H5928_006_0	11	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H5928	007	0	1	01	01	H5928_007_0	11	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H5928	007	0	1	01	01	H5928_007_0	11	5	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							2			90							30		31	14	31	14					261.00	25		25																							25																	25				25			25			
H5928	007	0	1	01	01	H5928_007_0	11	3	Preferred Brand	1	4	000001	1	1	110100000010001000000001	30		90							2			90							30				31	14					43.81	25		25																							25																	25							25			
H5928	007	0	1	01	01	H5928_007_0	11	4	Non-Preferred Brand	1	4	100100	1	1	110100000010001000000111	30		90							2			90							30		31	14	31	14					39.16	25		25																							25																	25				25			25			
H5928	007	0	1	01	01	H5928_007_0	11	2	Non-Preferred Generic	1	4	000100	1	1	010100000010001000000110	30		90							2			90							30		31	14							4.30	25		25																							25																	25				25						
H5928	007	0	1	01	01	H5928_007_0	11	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5928	009	0	1	01	01	H5928_009_0	11	5	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							2			90							30		31	14	31	14					261.00	25		25																							25																	25				25			25			
H5928	009	0	1	01	01	H5928_009_0	11	4	Non-Preferred Brand	1	4	100100	1	1	110100000010001000000111	30		90							2			90							30		31	14	31	14					39.16	25		25																							25																	25				25			25			
H5928	009	0	1	01	01	H5928_009_0	11	3	Preferred Brand	1	4	000001	1	1	110100000010001000000001	30		90							2			90							30				31	14					43.81	25		25																							25																	25							25			
H5928	009	0	1	01	01	H5928_009_0	11	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5928	009	0	1	01	01	H5928_009_0	11	2	Non-Preferred Generic	1	4	000100	1	1	010100000010001000000110	30		90							2			90							30		31	14							4.30	25		25																							25																	25				25						
H5928	009	0	1	01	01	H5928_009_0	11	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H5928	010	0	1	01	01	H5928_010_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5928	010	0	1	01	01	H5928_010_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				5.00		10.00																								10.00																		5.00					5.00							
H5928	010	0	1	01	01	H5928_010_0	10	4	Non-Preferred Brand	1	4	100100	1	2	110100000010001000000111	30		90							2			90							30		31	14	31	14		50.00		100.00																								100.00																		50.00					50.00			50.00				
H5928	010	0	1	01	01	H5928_010_0	10	5	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							2			90							30		31	14	31	14					532.73	30		30																							30																	30				30			30			
H5928	010	0	1	01	01	H5928_010_0	10	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H5928	010	0	1	01	01	H5928_010_0	10	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				5.00		10.00																								10.00																		5.00					5.00					1		
H5928	010	0	1	01	01	H5928_010_0	10	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		30.00		60.00																								60.00																		30.00								30.00				
H5928	012	0	1	01	01	H5928_012_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5928	012	0	1	01	01	H5928_012_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				5.00		10.00																								10.00																		5.00					5.00							
H5928	012	0	1	01	01	H5928_012_0	10	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		30.00		60.00																								60.00																		30.00								30.00				
H5928	012	0	1	01	01	H5928_012_0	10	4	Non-Preferred Brand	1	4	100100	1	2	110100000010001000000111	30		90							2			90							30		31	14	31	14		50.00		100.00																								100.00																		50.00					50.00			50.00				
H5928	012	0	1	01	01	H5928_012_0	10	5	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							2			90							30		31	14	31	14					532.73	30		30																							30																	30				30			30			
H5928	012	0	1	01	01	H5928_012_0	10	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H5928	012	0	1	01	01	H5928_012_0	10	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				5.00		10.00																								10.00																		5.00					5.00					1		
H5928	016	0	1	01	01	H5928_016_0	10	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H5928	016	0	1	01	01	H5928_016_0	10	5	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							2			90							30		31	14	31	14					532.73	30		30																							30																	30				30			30			
H5928	016	0	1	01	01	H5928_016_0	10	4	Non-Preferred Brand	1	4	100100	1	2	110100000010001000000111	30		90							2			90							30		31	14	31	14		50.00		100.00																								100.00																		50.00					50.00			50.00				
H5928	016	0	1	01	01	H5928_016_0	10	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		30.00		60.00																								60.00																		30.00								30.00				
H5928	016	0	1	01	01	H5928_016_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				5.00		10.00																								10.00																		5.00					5.00							
H5928	016	0	1	01	01	H5928_016_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5928	016	0	1	01	01	H5928_016_0	10	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				5.00		10.00																								10.00																		5.00					5.00					1		
H5928	018	0	1	01	01	H5928_018_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5928	018	0	1	01	01	H5928_018_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				5.00		10.00																								10.00																		5.00					5.00							
H5928	018	0	1	01	01	H5928_018_0	10	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		30.00		60.00																								60.00																		30.00								30.00				
H5928	018	0	1	01	01	H5928_018_0	10	4	Non-Preferred Brand	1	4	100100	1	2	110100000010001000000111	30		90							2			90							30		31	14	31	14		50.00		100.00																								100.00																		50.00					50.00			50.00				
H5928	018	0	1	01	01	H5928_018_0	10	5	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							2			90							30		31	14	31	14					532.73	30		30																							30																	30				30			30			
H5928	018	0	1	01	01	H5928_018_0	10	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H5928	018	0	1	01	01	H5928_018_0	10	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				5.00		10.00																								10.00																		5.00					5.00					1		
H5928	020	0	1	01	01	H5928_020_0	9	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				5.00		10.00																								10.00																		5.00					5.00					1		
H5928	020	0	1	01	01	H5928_020_0	9	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H5928	020	0	1	01	01	H5928_020_0	9	5	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							2			90							30		31	14	31	14					532.73	30		30																							30																	30				30			30			
H5928	020	0	1	01	01	H5928_020_0	9	4	Non-Preferred Brand	1	4	100100	1	2	110100000010001000000111	30		90							2			90							30		31	14	31	14		50.00		100.00																								100.00																		50.00					50.00			50.00				
H5928	020	0	1	01	01	H5928_020_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		30.00		60.00																								60.00																		30.00								30.00				
H5928	020	0	1	01	01	H5928_020_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				5.00		10.00																								10.00																		5.00					5.00							
H5928	020	0	1	01	01	H5928_020_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5928	022	0	1	01	01	H5928_022_0	9	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H5928	022	0	1	01	01	H5928_022_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5928	022	0	1	01	01	H5928_022_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				5.00		10.00																								10.00																		5.00					5.00							
H5928	022	0	1	01	01	H5928_022_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		30.00		60.00																								60.00																		30.00								30.00				
H5928	022	0	1	01	01	H5928_022_0	9	4	Non-Preferred Brand	1	4	100100	1	2	110100000010001000000111	30		90							2			90							30		31	14	31	14		50.00		100.00																								100.00																		50.00					50.00			50.00				
H5928	022	0	1	01	01	H5928_022_0	9	5	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							2			90							30		31	14	31	14					532.73	30		30																							30																	30				30			30			
H5928	022	0	1	01	01	H5928_022_0	9	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				5.00		10.00																								10.00																		5.00					5.00					1		
H5928	024	0	1	01	01	H5928_024_0	10	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H5928	024	0	1	01	01	H5928_024_0	10	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				5.00		10.00																								10.00																		5.00					5.00					1		
H5928	024	0	1	01	01	H5928_024_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5928	024	0	1	01	01	H5928_024_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				5.00		10.00																								10.00																		5.00					5.00							
H5928	024	0	1	01	01	H5928_024_0	10	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		30.00		60.00																								60.00																		30.00								30.00				
H5928	024	0	1	01	01	H5928_024_0	10	4	Non-Preferred Brand	1	4	100100	1	2	110100000010001000000111	30		90							2			90							30		31	14	31	14		50.00		100.00																								100.00																		50.00					50.00			50.00				
H5928	024	0	1	01	01	H5928_024_0	10	5	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							2			90							30		31	14	31	14					532.73	30		30																							30																	30				30			30			
H5928	025	0	1	01	01	H5928_025_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5928	025	0	1	01	01	H5928_025_0	9	2	Non-Preferred Generic	1	4	000100	1	1	010100000010001000000110	30		90							2			90							30		31	14							4.30	25		25																							25																	25				25						
H5928	025	0	1	01	01	H5928_025_0	9	3	Preferred Brand	1	4	000001	1	1	110100000010001000000001	30		90							2			90							30				31	14					43.81	25		25																							25																	25							25			
H5928	025	0	1	01	01	H5928_025_0	9	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H5928	025	0	1	01	01	H5928_025_0	9	5	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							2			90							30		31	14	31	14					261.00	25		25																							25																	25				25			25			
H5928	025	0	1	01	01	H5928_025_0	9	4	Non-Preferred Brand	1	4	100100	1	1	110100000010001000000111	30		90							2			90							30		31	14	31	14					39.16	25		25																							25																	25				25			25			
H5928	026	0	1	01	01	H5928_026_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5928	026	0	1	01	01	H5928_026_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				5.00		10.00																								10.00																		5.00					5.00							
H5928	026	0	1	01	01	H5928_026_0	10	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		30.00		60.00																								60.00																		30.00								30.00				
H5928	026	0	1	01	01	H5928_026_0	10	4	Non-Preferred Brand	1	4	100100	1	2	110100000010001000000111	30		90							2			90							30		31	14	31	14		50.00		100.00																								100.00																		50.00					50.00			50.00				
H5928	026	0	1	01	01	H5928_026_0	10	5	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							2			90							30		31	14	31	14					532.73	30		30																							30																	30				30			30			
H5928	026	0	1	01	01	H5928_026_0	10	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H5928	026	0	1	01	01	H5928_026_0	10	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				5.00		10.00																								10.00																		5.00					5.00					1		
H5928	027	0	1	01	01	H5928_027_0	9	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H5928	027	0	1	01	01	H5928_027_0	9	5	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							2			90							30		31	14	31	14					261.00	25		25																							25																	25				25			25			
H5928	027	0	1	01	01	H5928_027_0	9	4	Non-Preferred Brand	1	4	100100	1	1	110100000010001000000111	30		90							2			90							30		31	14	31	14					39.16	25		25																							25																	25				25			25			
H5928	027	0	1	01	01	H5928_027_0	9	3	Preferred Brand	1	4	000001	1	1	110100000010001000000001	30		90							2			90							30				31	14					43.81	25		25																							25																	25							25			
H5928	027	0	1	01	01	H5928_027_0	9	2	Non-Preferred Generic	1	4	000100	1	1	010100000010001000000110	30		90							2			90							30		31	14							4.30	25		25																							25																	25				25						
H5928	027	0	1	01	01	H5928_027_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5928	031	0	1	01	01	H5928_031_0	10	4	Non-Preferred Brand	1	4	100100	1	1	110100000010001000000111	30		90							2			90							30		31	14	31	14					39.16	25		25																							25																	25				25			25			
H5928	031	0	1	01	01	H5928_031_0	10	3	Preferred Brand	1	4	000001	1	1	110100000010001000000001	30		90							2			90							30				31	14					43.81	25		25																							25																	25							25			
H5928	031	0	1	01	01	H5928_031_0	10	2	Non-Preferred Generic	1	4	000100	1	1	010100000010001000000110	30		90							2			90							30		31	14							4.30	25		25																							25																	25				25						
H5928	031	0	1	01	01	H5928_031_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5928	031	0	1	01	01	H5928_031_0	10	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							2			90							30		31	14				0.00		0.00																								0.00																		0.00					0.00					1		
H5928	031	0	1	01	01	H5928_031_0	10	5	Specialty Tier	1	4	010010	1	1	110100000010001000000111	30		90							2			90							30		31	14	31	14					261.00	25		25																							25																	25				25			25			
H5932	007	0	1	01	01	H5932_007_0	4	4	Non-Preferred Brand	1	4	100000	1	2	111100000010001000000001	30	60	90							1			90							30				31	14		95.00	190.00	285.00																								285.00																		95.00								95.00				
H5932	007	0	1	01	01	H5932_007_0	4	3	Preferred Brand	1	4	000001	1	2	111100000010001000000001	30	60	90							1			90							30				31	14		45.00	90.00	135.00																								135.00																		45.00								45.00				
H5932	007	0	1	01	01	H5932_007_0	4	2	Non-Preferred Generic	1	4	000100	1	2	011100000010001000000100	30	60	90							1			90							30		31					10.00	20.00	30.00																								30.00																		10.00					10.00							
H5932	007	0	1	01	01	H5932_007_0	4	1	Preferred Generic	1	4	001000	1	2	011100000010001000000100	30	60	90							1			90							30		31					4.00	8.00	12.00																								12.00																		4.00					4.00							
H5932	007	0	1	01	01	H5932_007_0	4	5	Specialty Tier	1	4	010010	1	1	111100000010001000000101	30	60	90							1			90							30		31		31	14					440.00	33	33	33																							33																	33				33			33			
H5932	008	0	1	01	01	H5932_008_0	4	4	Non-Preferred Brand	1	4	100000	1	2	111100000010001000000001	30	60	90							1			90							30				31	14		95.00	190.00	285.00																								285.00																		95.00								95.00				
H5932	008	0	1	01	01	H5932_008_0	4	2	Non-Preferred Generic	1	4	000100	1	2	011100000010001000000100	30	60	90							1			90							30		31					10.00	20.00	30.00																								30.00																		10.00					10.00							
H5932	008	0	1	01	01	H5932_008_0	4	1	Preferred Generic	1	4	001000	1	2	011100000010001000000100	30	60	90							1			90							30		31					0.00	0.00	0.00																								0.00																		0.00					0.00							
H5932	008	0	1	01	01	H5932_008_0	4	5	Specialty Tier	1	4	010010	1	1	111100000010001000000101	30	60	90							1			90							30		31		31	14					440.00	33	33	33																							33																	33				33			33			
H5932	008	0	1	01	01	H5932_008_0	4	3	Preferred Brand	1	4	000001	1	2	111100000010001000000001	30	60	90							1			90							30				31	14		45.00	90.00	135.00																								135.00																		45.00								45.00				
H5938	001	0	1	01	01	H5938_001_0	7	5	Specialty Tier	1	4	010010	1	4	110000000010000000000101	30																			30		31		31	14		250.00			250.00	25																																								250.00		25			250.00	25		250.00	25			
H5938	001	0	1	01	01	H5938_001_0	7	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					7.00	14.00	21.00																						7.00	14.00	17.50																		7.00					7.00							
H5938	001	0	1	01	01	H5938_001_0	7	3	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		40.00	80.00	120.00																						40.00	80.00	100.00																		40.00								40.00				
H5938	001	0	1	01	01	H5938_001_0	7	1	Preferred Generic	1	4	001000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					3.00	6.00	9.00																						3.00	6.00	7.50																		3.00					3.00							
H5938	001	0	1	01	01	H5938_001_0	7	4	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		80.00	160.00	240.00																						80.00	160.00	200.00																		80.00								80.00				
H5938	006	0	1	01	01	H5938_006_0	6	3	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		40.00	80.00	120.00																						40.00	80.00	100.00																		40.00								40.00				
H5938	006	0	1	01	01	H5938_006_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					7.00	14.00	21.00																						7.00	14.00	17.50																		7.00					7.00							
H5938	006	0	1	01	01	H5938_006_0	6	1	Preferred Generic	1	4	001000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					3.00	6.00	9.00																						3.00	6.00	7.50																		3.00					3.00							
H5938	006	0	1	01	01	H5938_006_0	6	2	Non-Preferred Generic	3	4	000100	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					7.00	14.00	21.00																						7.00	14.00	17.50																		7.00					7.00					1		
H5938	006	0	1	01	01	H5938_006_0	6	1	Preferred Generic	3	4	001000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					3.00	6.00	9.00																						3.00	6.00	7.50																		3.00					3.00					1		
H5938	006	0	1	01	01	H5938_006_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		80.00	160.00	240.00																						80.00	160.00	200.00																		80.00								80.00				
H5938	006	0	1	01	01	H5938_006_0	6	5	Specialty Tier	1	4	010010	1	4	110000000010000000000101	30																			30		31		31	14		250.00			250.00	25																																								250.00		25			250.00	25		250.00	25			
H5943	001	0	1	02	01	H5943_001_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				0.00		0.00																								0.00																		0.00					0.00							
H5943	001	0	1	02	01	H5943_001_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	31		90							1			90							31		31	14				10.00		30.00																								25.00																		10.00					10.00							
H5943	001	0	1	02	01	H5943_001_0	7	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	31		90							1			90							31				31	14		0.00		0.00																								0.00																		0.00								0.00				
H5943	001	0	1	02	01	H5943_001_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	31		90							1			90							31				31	14		65.00		195.00																								185.00																		65.00								65.00				
H5943	001	0	1	02	01	H5943_001_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000000000111	31																			31		31	14	31	14					373.13	25																																										25				25			25			
H5943	001	0	1	02	01	H5943_001_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	31		90							1			90							31				31	14		40.00		120.00																								110.00																		40.00								40.00				
H5950	001	0	1	01	01	H5950_001_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H5950	001	0	1	01	01	H5950_001_0	6	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H5950	001	0	1	01	01	H5950_001_0	6	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					7.00	14.00	21.00																													7.00	14.00	14.00					7.00	14.00	21.00					7.00				7.00							
H5950	001	0	1	01	01	H5950_001_0	6	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					328.91	33	33	33																												33	33	33					33	33	33				33			33			33			
H5950	001	0	1	01	01	H5950_001_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H5969	001	0	1	01	01	H5969_001_0	11	1	Preferred Generic	1	4	001000	1	2	010100000010101000000110	30		90							1	30		90							30		31	14				4.00		12.00																						4.00		8.00																		4.00					4.00							
H5969	001	0	1	01	01	H5969_001_0	11	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000110	30		90							1	30		90							30		31	14				7.00		21.00																						7.00		14.00																		7.00					7.00							
H5969	001	0	1	01	01	H5969_001_0	11	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							1	30		90							30				31	14		40.00		120.00																						40.00		80.00																		40.00								40.00				
H5969	001	0	1	01	01	H5969_001_0	11	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							1	30		90							30				31	14		80.00		240.00																						80.00		160.00																		80.00								80.00				
H5969	001	0	1	01	01	H5969_001_0	11	5	Specialty Tier	1	4	100001	1	1	110100000010101000000001	30		90							1	30		90							30				31	14					473.84	33		33																					33		33																	33							33			
H5970	001	0	1	04	01	H5970_001_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H5970	001	0	1	04	01	H5970_001_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H5970	001	0	1	04	01	H5970_001_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H5970	001	0	1	04	01	H5970_001_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H5970	001	0	1	04	01	H5970_001_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					953.00	33																														33							33					33				33			33	2	3	
H5970	001	0	1	04	01	H5970_001_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H5970	001	0	1	04	01	H5970_001_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H5970	001	0	1	04	01	H5970_001_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H5970	001	0	1	04	01	H5970_001_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H5970	001	0	1	04	01	H5970_001_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					876.00	33																														33							33					33				33			33			
H5970	002	0	1	04	01	H5970_002_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H5970	002	0	1	04	01	H5970_002_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H5970	002	0	1	04	01	H5970_002_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H5970	002	0	1	04	01	H5970_002_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H5970	002	0	1	04	01	H5970_002_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					677.00	33																														33							33					33				33			33			
H5970	002	0	1	04	01	H5970_002_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H5970	002	0	1	04	01	H5970_002_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H5970	002	0	1	04	01	H5970_002_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H5970	002	0	1	04	01	H5970_002_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H5970	002	0	1	04	01	H5970_002_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					733.00	33																														33							33					33				33			33	2	3	
H5970	004	0	1	04	01	H5970_004_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					928.00	33																														33							33					33				33			33	2	3	
H5970	004	0	1	04	01	H5970_004_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H5970	004	0	1	04	01	H5970_004_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H5970	004	0	1	04	01	H5970_004_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H5970	004	0	1	04	01	H5970_004_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H5970	004	0	1	04	01	H5970_004_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					850.00	33																														33							33					33				33			33			
H5970	004	0	1	04	01	H5970_004_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H5970	004	0	1	04	01	H5970_004_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H5970	004	0	1	04	01	H5970_004_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H5970	004	0	1	04	01	H5970_004_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H5970	005	0	1	04	01	H5970_005_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H5970	005	0	1	04	01	H5970_005_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H5970	005	0	1	04	01	H5970_005_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					835.00	33																														33							33					33				33			33			
H5970	005	0	1	04	01	H5970_005_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H5970	005	0	1	04	01	H5970_005_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H5970	005	0	1	04	01	H5970_005_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H5970	005	0	1	04	01	H5970_005_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H5970	005	0	1	04	01	H5970_005_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H5970	005	0	1	04	01	H5970_005_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H5970	005	0	1	04	01	H5970_005_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					945.00	33																														33							33					33				33			33	2	3	
H5970	006	0	1	04	01	H5970_006_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H5970	006	0	1	04	01	H5970_006_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H5970	006	0	1	04	01	H5970_006_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H5970	006	0	1	04	01	H5970_006_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H5970	006	0	1	04	01	H5970_006_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					945.00	33																														33							33					33				33			33	2	3	
H5970	006	0	1	04	01	H5970_006_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H5970	006	0	1	04	01	H5970_006_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					835.00	33																														33							33					33				33			33			
H5970	006	0	1	04	01	H5970_006_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H5970	006	0	1	04	01	H5970_006_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H5970	006	0	1	04	01	H5970_006_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H5970	008	0	1	04	01	H5970_008_0	8	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					984.00	33																														33							33					33				33			33	2	3	
H5970	008	0	1	04	01	H5970_008_0	8	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H5970	008	0	1	04	01	H5970_008_0	8	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H5970	008	0	1	04	01	H5970_008_0	8	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H5970	008	0	1	04	01	H5970_008_0	8	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H5970	008	0	1	04	01	H5970_008_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					874.00	33																														33							33					33				33			33			
H5970	008	0	1	04	01	H5970_008_0	8	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H5970	008	0	1	04	01	H5970_008_0	8	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H5970	008	0	1	04	01	H5970_008_0	8	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H5970	008	0	1	04	01	H5970_008_0	8	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H5970	009	0	1	04	01	H5970_009_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H5970	009	0	1	04	01	H5970_009_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					874.00	33																														33							33					33				33			33			
H5970	009	0	1	04	01	H5970_009_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H5970	009	0	1	04	01	H5970_009_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H5970	009	0	1	04	01	H5970_009_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H5970	009	0	1	04	01	H5970_009_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H5970	009	0	1	04	01	H5970_009_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					984.00	33																														33							33					33				33			33	2	3	
H5970	009	0	1	04	01	H5970_009_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H5970	009	0	1	04	01	H5970_009_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H5970	009	0	1	04	01	H5970_009_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H5970	010	0	1	04	01	H5970_010_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H5970	010	0	1	04	01	H5970_010_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H5970	010	0	1	04	01	H5970_010_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H5970	010	0	1	04	01	H5970_010_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H5970	010	0	1	04	01	H5970_010_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					984.00	33																														33							33					33				33			33	2	3	
H5970	010	0	1	04	01	H5970_010_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H5970	010	0	1	04	01	H5970_010_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H5970	010	0	1	04	01	H5970_010_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H5970	010	0	1	04	01	H5970_010_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H5970	010	0	1	04	01	H5970_010_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					874.00	33																														33							33					33				33			33			
H5985	001	0	1	01	01	H5985_001_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							1	30		90							30				31	14		35.00		105.00																						35.00		105.00																		35.00								35.00				
H5985	001	0	1	01	01	H5985_001_0	7	4	Specialty Tier	1	4	000101	1	1	110000000010100000000111	30										30									30		31	14	31	14					550.22	25																							25																			25				25			25			
H5985	001	0	1	01	01	H5985_001_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000110	30		90							1	30		90							30		31	14				10.00		30.00																						10.00		30.00																		10.00					10.00							
H5985	001	0	1	01	01	H5985_001_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							1	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00							
H5989	002	0	1	01	01	H5989_002_0	10	2	Preferred Brand	1	3	000001		2	110100000010001000000001	30		90							1			90							30				31	14		42.00		126.00																								126.00																		42.00								42.00				
H5989	002	0	1	01	01	H5989_002_0	10	4	Specialty Tier	1	3	010010		1	110100000010001000000111	30		90							2			90							30		31	14	31	14					299.85	25		25																							25																	25				25			25			
H5989	002	0	1	01	01	H5989_002_0	10	3	Non-Preferred Brand	1	3	100000		2	110100000010001000000001	30		90							1			90							30				31	14		95.00		285.00																								285.00																		95.00								95.00				
H5989	002	0	1	01	01	H5989_002_0	10	1	Generic	1	3	010000		2	010100000010001000000110	30		90							1			90							30		31	14				7.25		21.75																								21.75																		7.25					7.25							
H5989	008	0	1	01	01	H5989_008_0	10	2	Preferred Brand	1	3	000001		2	110100000010001000000001	30		90							1			90							30				31	14		45.00		135.00																								135.00																		45.00								45.00				
H5989	008	0	1	01	01	H5989_008_0	10	3	Non-Preferred Brand	1	3	100000		2	110100000010001000000001	30		90							1			90							30				31	14		95.00		285.00																								285.00																		95.00								95.00				
H5989	008	0	1	01	01	H5989_008_0	10	1	Generic	1	3	010000		2	010100000010001000000110	30		90							1			90							30		31	14				8.00		24.00																								24.00																		8.00					8.00							
H5989	008	0	1	01	01	H5989_008_0	10	4	Specialty Tier	1	3	010010		1	110100000010001000000111	30		90							2			90							30		31	14	31	14					303.61	28		28																							28																	28				28			28			
H5991	001	0	1	01	01	H5991_001_0	11	1	Generic	1	4	010000	1	1	011100000010111000000110	30	60	90							1	30	60	90							30		31	14							0.00	0	0	0																					0	0	0																	0				0						
H5991	001	0	1	01	01	H5991_001_0	11	2	Brand	1	4	000010	1	1	111100000010111000000001	30	60	90							1	30	60	90							30				31	14					25.00	25	25	25																					25	25	25																	25							25			
H5992	006	0	1	01	01	H5992_006_0	6	1	Generic	1	4	010000	3	2	011100000010111000000110	30	60	90							2	30	60	90							30		31	14			0.00	0.00	0.00	0.00																					0.00	0.00	0.00	0.00																		0.00				0.00	0.00							
H5992	006	0	1	01	01	H5992_006_0	6	2	Brand	1	4	000010	1	2	111100000010111000000001	30	60	90							2	30	60	90							30				31	14	1.50	45.00	90.00	135.00																						45.00	90.00	135.00																		45.00								45.00				
H5992	006	0	1	01	01	H5992_006_0	6	1	Generic	3	4	010000	3	2	011100000010111000000110	30	60	90							2	30	60	90							30		31	14			0.00	0.00	0.00	0.00																						0.00	0.00	0.00																		0.00				0.00	0.00					2		2
H6169	021	0	1	09	04	H6169_021_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		80.00		200.00																													80.00		160.00					80.00		200.00				80.00								80.00				
H6169	021	0	1	09	04	H6169_021_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		40.00		100.00																													40.00		80.00					40.00		100.00				40.00								40.00				
H6169	021	0	1	09	04	H6169_021_0	6	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		7.00		17.50																													7.00		14.00					7.00		17.50				7.00					7.00			7.00				
H6169	021	0	1	09	04	H6169_021_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					2.00		5.00																													2.00		4.00					2.00		5.00				2.00					2.00							
H6169	021	0	1	09	04	H6169_021_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					500.00	33																														33							33					33				33			33			
H6169	024	0	1	09	04	H6169_024_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		80.00		200.00																													80.00		160.00					80.00		200.00				80.00								80.00				
H6169	024	0	1	09	04	H6169_024_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		40.00		100.00																													40.00		80.00					40.00		100.00				40.00								40.00				
H6169	024	0	1	09	04	H6169_024_0	6	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		7.00		17.50																													7.00		14.00					7.00		17.50				7.00					7.00			7.00				
H6169	024	0	1	09	04	H6169_024_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					2.00		5.00																													2.00		4.00					2.00		5.00				2.00					2.00							
H6169	024	0	1	09	04	H6169_024_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					500.00	33																														33							33					33				33			33			
H6169	031	0	1	09	04	H6169_031_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					5.00		12.50																													5.00		10.00					5.00		12.50				5.00					5.00							
H6169	031	0	1	09	04	H6169_031_0	6	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		12.00		30.00																													12.00		24.00					12.00		30.00				12.00					12.00			12.00				
H6169	031	0	1	09	04	H6169_031_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					435.00	29																														29							29					29				29			29			
H6169	031	0	1	09	04	H6169_031_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		45.00		112.50																													45.00		90.00					45.00		112.50				45.00								45.00				
H6169	031	0	1	09	04	H6169_031_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		95.00		237.50																													95.00		190.00					95.00		237.50				95.00								95.00				
H6169	032	0	1	09	04	H6169_032_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					5.00		12.50																													5.00		10.00					5.00		12.50				5.00					5.00							
H6169	032	0	1	09	04	H6169_032_0	6	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		12.00		30.00																													12.00		24.00					12.00		30.00				12.00					12.00			12.00				
H6169	032	0	1	09	04	H6169_032_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		45.00		112.50																													45.00		90.00					45.00		112.50				45.00								45.00				
H6169	032	0	1	09	04	H6169_032_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		95.00		237.50																													95.00		190.00					95.00		237.50				95.00								95.00				
H6169	032	0	1	09	04	H6169_032_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					435.00	29																														29							29					29				29			29			
H6169	033	0	1	09	04	H6169_033_0	6	4	Non-Preferred Brand	1	3	100000		2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		95.00		237.50																													95.00		190.00					95.00		237.50				95.00								95.00				
H6169	033	0	1	09	04	H6169_033_0	6	3	Preferred Brand	1	3	000001		2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		45.00		112.50																													45.00		90.00					45.00		112.50				45.00								45.00				
H6169	033	0	1	09	04	H6169_033_0	6	2	Non-Preferred Generic	1	3	000110		2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		12.00		30.00																													12.00		24.00					12.00		30.00				12.00					12.00			12.00				
H6169	033	0	1	09	04	H6169_033_0	6	1	Preferred Generic	1	3	001000		2	010100000010000101101100	30		90							2				30		90	30		90	30		34					5.00		12.50																													5.00		10.00					5.00		12.50				5.00					5.00							
H6169	033	0	1	09	04	H6169_033_0	6	5	Specialty Tier	1	3	010010		1	110000000010000100100101	30													30			30			30		34		34	14					435.00	29																														29							29					29				29			29			
H6169	035	0	1	09	04	H6169_035_0	6	5	Specialty Tier	1	3	010010		1	110000000010000100100101	30													30			30			30		34		34	14					435.00	29																														29							29					29				29			29			
H6169	035	0	1	09	04	H6169_035_0	6	4	Non-Preferred Brand	1	3	100000		2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		95.00		237.50																													95.00		190.00					95.00		237.50				95.00								95.00				
H6169	035	0	1	09	04	H6169_035_0	6	3	Preferred Brand	1	3	000001		2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		45.00		112.50																													45.00		90.00					45.00		112.50				45.00								45.00				
H6169	035	0	1	09	04	H6169_035_0	6	1	Preferred Generic	1	3	001000		2	010100000010000101101100	30		90							2				30		90	30		90	30		34					5.00		12.50																													5.00		10.00					5.00		12.50				5.00					5.00							
H6169	035	0	1	09	04	H6169_035_0	6	2	Non-Preferred Generic	1	3	000110		2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		12.00		30.00																													12.00		24.00					12.00		30.00				12.00					12.00			12.00				
H6169	036	0	1	09	04	H6169_036_0	6	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		12.00		30.00																													12.00		24.00					12.00		30.00				12.00					12.00			12.00				
H6169	036	0	1	09	04	H6169_036_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		45.00		112.50																													45.00		90.00					45.00		112.50				45.00								45.00				
H6169	036	0	1	09	04	H6169_036_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					435.00	29																														29							29					29				29			29			
H6169	036	0	1	09	04	H6169_036_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		95.00		237.50																													95.00		190.00					95.00		237.50				95.00								95.00				
H6169	036	0	1	09	04	H6169_036_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					5.00		12.50																													5.00		10.00					5.00		12.50				5.00					5.00							
H6169	054	0	1	09	04	H6169_054_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		80.00		200.00																													80.00		160.00					80.00		200.00				80.00								80.00				
H6169	054	0	1	09	04	H6169_054_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		40.00		100.00																													40.00		80.00					40.00		100.00				40.00								40.00				
H6169	054	0	1	09	04	H6169_054_0	6	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		7.00		17.50																													7.00		14.00					7.00		17.50				7.00					7.00			7.00				
H6169	054	0	1	09	04	H6169_054_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					500.00	33																														33							33					33				33			33			
H6169	054	0	1	09	04	H6169_054_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					2.00		5.00																													2.00		4.00					2.00		5.00				2.00					2.00							
H6169	056	0	1	09	04	H6169_056_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					500.00	33																														33							33					33				33			33			
H6169	056	0	1	09	04	H6169_056_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		80.00		200.00																													80.00		160.00					80.00		200.00				80.00								80.00				
H6169	056	0	1	09	04	H6169_056_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		40.00		100.00																													40.00		80.00					40.00		100.00				40.00								40.00				
H6169	056	0	1	09	04	H6169_056_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					2.00		5.00																													2.00		4.00					2.00		5.00				2.00					2.00							
H6169	056	0	1	09	04	H6169_056_0	6	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		7.00		17.50																													7.00		14.00					7.00		17.50				7.00					7.00			7.00				
H6169	057	0	1	09	04	H6169_057_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	30		90							2				30		90	30		90	30		34					2.00		5.00																													2.00		4.00					2.00		5.00				2.00					2.00							
H6169	057	0	1	09	04	H6169_057_0	6	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		34		34	14		7.00		17.50																													7.00		14.00					7.00		17.50				7.00					7.00			7.00				
H6169	057	0	1	09	04	H6169_057_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		40.00		100.00																													40.00		80.00					40.00		100.00				40.00								40.00				
H6169	057	0	1	09	04	H6169_057_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	30		90							2				30		90	30		90	30				34	14		80.00		200.00																													80.00		160.00					80.00		200.00				80.00								80.00				
H6169	057	0	1	09	04	H6169_057_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		34		34	14					500.00	33																														33							33					33				33			33			
H6178	001	0	1	01	01	H6178_001_0	8	1	Generic	1	4	010001	1	2	110100000010001000000101	30		90							2			90							30		31		31	14		0.00		0.00																								0.00																		0.00					0.00			0.00				
H6178	001	0	1	01	01	H6178_001_0	8	4	Specialty Tier	1	4	010010	1	1	110100000010001000000101	30		90							2			90							30		31		31	14					448.24	25		25																							25																	25				25			25			
H6178	001	0	1	01	01	H6178_001_0	8	3	Non-Preferred Brand	1	4	100100	1	2	110100000010001000000101	30		90							2			90							30		31		31	14		95.00		285.00																								285.00																		95.00					95.00			95.00				
H6178	001	0	1	01	01	H6178_001_0	8	2	Preferred Brand	1	4	000101	1	2	110100000010001000000101	30		90							2			90							30		31		31	14		45.00		135.00																								135.00																		45.00					45.00			45.00				
H6181	007	0	1	01	01	H6181_007_0	6	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	31	62	93							2	31	62	93							31		31	1				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	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	31	62	93							2	31	62	93							31		31	1				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	6	3	Preferred Brand	1	4	000001	1	1	111100000010111000000001	31	62	93							2	31	62	93							31				31	1					44.00	25	25	25																					25	25	25																	25							25			
H6181	007	0	1	01	01	H6181_007_0	6	4	Non-Preferred Brand	1	4	100000	1	1	111100000010111000000001	31	62	93							2	31	62	93							31				31	1					83.00	25	25	25																					25	25	25																	25							25			
H6181	007	0	1	01	01	H6181_007_0	6	5	Specialty Tier	1	4	100100	1	1	111100000010111000000111	31	62	93							2	31	62	93							31		31	1	31	1					401.00	25	25	25																					25	25	25																	25				25			25			
H6181	007	0	1	01	01	H6181_007_0	6	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	31	62	93							2	31	62	93							31		31	1				0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00			0.00		1		
H6181	007	0	1	01	01	H6181_007_0	6	2	Non-Preferred Generic	3	4	000100	1	2	011100000010111000000110	31	62	93							2	31	62	93							31		31	1				0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00					1		
H6181	009	0	1	01	01	H6181_009_0	7	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	31	62	93							2	31	62	93							31		31	1				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	7	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	31	62	93							2	31	62	93							31		31	1				4.00	8.00	12.00																						4.00	6.00	8.00																		4.00					4.00							
H6181	009	0	1	01	01	H6181_009_0	7	3	Preferred Brand	1	4	000001	1	2	111100000010111000000001	31	62	93							2	31	62	93							31				31	1		35.00	70.00	105.00																						35.00	52.50	70.00																		35.00								35.00				
H6181	009	0	1	01	01	H6181_009_0	7	4	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	31	62	93							2	31	62	93							31				31	1		80.00	160.00	240.00																						80.00	120.00	160.00																		80.00								80.00				
H6181	009	0	1	01	01	H6181_009_0	7	5	Specialty Tier	1	4	100100	1	1	111100000010111000000111	31	62	93							2	31	62	93							31		31	1	31	1					501.00	33	33	33																					33	33	33																	33				33			33			
H6181	009	0	1	01	01	H6181_009_0	7	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	31	62	93							2	31	62	93							31		31	1				0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00					1		
H6181	015	0	1	02	01	H6181_015_0	7	3	Preferred Brand	1	4	000001	1	2	111100000010111000000001	31	62	93							2	31	62	93							31				31	1		40.00	80.00	120.00																						40.00	60.00	80.00																		40.00								40.00				
H6181	015	0	1	02	01	H6181_015_0	7	4	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	31	62	93							2	31	62	93							31				31	1		65.00	130.00	195.00																						65.00	97.50	130.00																		65.00								65.00				
H6181	015	0	1	02	01	H6181_015_0	7	5	Specialty Tier	1	4	100100	1	1	111100000010111000000111	31	62	93							2	31	62	93							31		31	1	31	1					398.00	25	25	25																					25	25	25																	25				25			25			
H6181	015	0	1	02	01	H6181_015_0	7	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	31	62	93							2	31	62	93							31		31	1				3.00	6.00	9.00																						3.00	4.50	6.00																		3.00					3.00					1		
H6181	015	0	1	02	01	H6181_015_0	7	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	31	62	93							2	31	62	93							31		31	1				3.00	6.00	9.00																						3.00	4.50	6.00																		3.00					3.00							
H6181	015	0	1	02	01	H6181_015_0	7	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	31	62	93							2	31	62	93							31		31	1				3.00	6.00	9.00																						3.00	4.50	6.00																		3.00					3.00							
H6306	002	0	1	01	01	H6306_002_0	8	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		31	14				25.00	50.00	75.00																						25.00	50.00	62.50																		25.00					25.00							
H6306	002	0	1	01	01	H6306_002_0	8	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		31	14				7.00	14.00	21.00																						7.00	14.00	21.00																		7.00					7.00					1		
H6306	002	0	1	01	01	H6306_002_0	8	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		31	14				7.00	14.00	21.00																						0.00	0.00	0.00																		7.00					7.00							
H6306	002	0	1	01	01	H6306_002_0	8	5	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					33.00	33	33	33																					33	33	33																	33				33			33			
H6306	002	0	1	01	01	H6306_002_0	8	4	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		80.00	160.00	240.00																						80.00	160.00	200.00																		80.00								80.00				
H6306	002	0	1	01	01	H6306_002_0	8	3	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		40.00	80.00	120.00																						40.00	80.00	100.00																		40.00								40.00				
H6328	001	0	1	04	01	H6328_001_0	4	3	Preferred Brand	1	4	000001	1	2	100010110101101000000001				30		90	30		90	1	30		90								29			31	14										33.00		99.00						33.00		99.00						33.00		99.00																			33.00							33.00				
H6328	001	0	1	04	01	H6328_001_0	4	1	Preferred Generic	1	4	001000	1	2	000010110101101000000100				30		90	30		90	1	30		90								29	31													0.00		0.00						4.00		12.00						4.00		12.00																			4.00				4.00							
H6328	001	0	1	04	01	H6328_001_0	4	4	Non-Preferred Brand	1	4	100000	1	2	100010110101101000000001				30		90	30		90	1	30		90								29			31	14										65.00		195.00						65.00		195.00						65.00		195.00																			65.00							65.00				
H6328	001	0	1	04	01	H6328_001_0	4	1	Preferred Generic	3	4	001000	1	2	000010110101101000000100				30		90	30		90	1	30		90								29	31													0.00		0.00						4.00		12.00						4.00		12.00																			4.00				4.00					1		
H6328	001	0	1	04	01	H6328_001_0	4	5	Specialty Tier	1	4	010010	1	1	100010110101101000000101				30		90	30		90	2	30		90								29	31		31	14													500.00	33		33					500.00	33		33					33		33																		33			33			33			
H6328	001	0	1	04	01	H6328_001_0	4	2	Non-Preferred Generic	1	4	000100	1	2	000010110101101000000100				30		90	30		90	1	30		90								29	31													10.00		30.00						10.00		30.00						10.00		30.00																			10.00				10.00							
H6328	002	0	1	04	01	H6328_002_0	5	1	Preferred Generic	3	4	001000	1	2	000010110101101000000100				30		90	30		90	1	30		90								29	31													0.00		0.00						5.00		15.00						5.00		15.00																			5.00				5.00					1		
H6328	002	0	1	04	01	H6328_002_0	5	1	Preferred Generic	1	4	001000	1	2	000010110101101000000100				30		90	30		90	1	30		90								29	31													0.00		0.00						5.00		15.00						5.00		15.00																			5.00				5.00							
H6328	002	0	1	04	01	H6328_002_0	5	5	Specialty Tier	1	4	010010	1	1	100010110101101000000101				30		90	30		90	2	30		90								29	31		31	14													500.00	33		33					500.00	33		33					33		33																		33			33			33			
H6328	002	0	1	04	01	H6328_002_0	5	2	Non-Preferred Generic	1	4	000100	1	2	000010110101101000000100				30		90	30		90	1	30		90								29	31													12.00		36.00						12.00		36.00						12.00		36.00																			12.00				12.00							
H6328	002	0	1	04	01	H6328_002_0	5	3	Preferred Brand	1	4	000001	1	2	100010110101101000000001				30		90	30		90	1	30		90								29			31	14										36.00		108.00						36.00		108.00						36.00		108.00																			36.00							36.00				
H6328	002	0	1	04	01	H6328_002_0	5	4	Non-Preferred Brand	1	4	100000	1	2	100010110101101000000001				30		90	30		90	1	30		90								29			31	14										68.00		204.00						68.00		204.00						68.00		204.00																			68.00							68.00				
H6328	003	0	1	04	01	H6328_003_0	5	1	Preferred Generic	3	4	001000	1	2	000010110101101000000100				30		90	30		90	1	30		90								29	31													2.00		6.00						8.00		24.00						8.00		24.00																			8.00				8.00					1		
H6328	003	0	1	04	01	H6328_003_0	5	5	Specialty Tier	1	4	010010	1	1	100010110101101000000101				30		90	30		90	2	30		90								29	31		31	14													500.00	33		33					500.00	33		33					33		33																		33			33			33			
H6328	003	0	1	04	01	H6328_003_0	5	2	Non-Preferred Generic	1	4	000100	1	2	000010110101101000000100				30		90	30		90	1	30		90								29	31													15.00		45.00						15.00		45.00						15.00		45.00																			15.00				15.00							
H6328	003	0	1	04	01	H6328_003_0	5	3	Preferred Brand	1	4	000001	1	2	100010110101101000000001				30		90	30		90	1	30		90								29			31	14										40.00		120.00						40.00		120.00						40.00		120.00																			40.00							40.00				
H6328	003	0	1	04	01	H6328_003_0	5	4	Non-Preferred Brand	1	4	100000	1	2	100010110101101000000001				30		90	30		90	1	30		90								29			31	14										70.00		210.00						70.00		210.00						70.00		210.00																			70.00							70.00				
H6328	003	0	1	04	01	H6328_003_0	5	1	Preferred Generic	1	4	001000	1	2	000010110101101000000100				30		90	30		90	1	30		90								29	31													2.00		6.00						8.00		24.00						8.00		24.00																			8.00				8.00							
H6360	001	0	1	18	06	H6360_001_0	7	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	31		90							2	31		90							31		31					5.00		15.00																						5.00		10.00																		5.00					5.00					1		
H6360	001	0	1	18	06	H6360_001_0	7	6	Vaccines	1	4	000001	1	2	110000000010000000000000	31																			31					1		0.00																																												0.00												
H6360	001	0	1	18	06	H6360_001_0	7	5	Specialty Tier	1	4	100001	1	1	110100000010101000000001	31		90							2	31		90							31				31	14					717.00	25		25																					25		25																	25							25			
H6360	001	0	1	18	06	H6360_001_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		90							2	31		90							31				31	14		65.00		195.00																						65.00		130.00																		65.00								65.00				
H6360	001	0	1	18	06	H6360_001_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		90							2	31		90							31				31	14		45.00		135.00																						45.00		90.00																		45.00								45.00				
H6360	001	0	1	18	06	H6360_001_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	31		90							2	31		90							31		31					10.00		30.00																						10.00		20.00																		10.00					10.00							
H6360	001	0	1	18	06	H6360_001_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	31		90							2	31		90							31		31					5.00		15.00																						5.00		10.00																		5.00					5.00							
H6360	001	0	1	18	06	H6360_001_0	7	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000100	31		90							2	31		90							31		31					10.00		30.00																						10.00		20.00																		10.00					10.00					1		
H6360	001	0	1	18	06	H6360_001_0	7	6	Vaccines	3	4	000001	1	2	110000000010000000000000	31																			31					1		0.00																																												0.00										1		
H6360	002	0	1	18	06	H6360_002_0	6	6	Vaccines	1	4	000001	1	2	110000000010000000000000	31																			31					1		0.00																																												0.00												
H6360	002	0	1	18	06	H6360_002_0	6	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	31		90							2	31		90							31		31					5.00		15.00																						5.00		10.00																		5.00					5.00					1		
H6360	002	0	1	18	06	H6360_002_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		90							2	31		90							31				31	14		45.00		135.00																						45.00		90.00																		45.00								45.00				
H6360	002	0	1	18	06	H6360_002_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	31		90							2	31		90							31		31					10.00		30.00																						10.00		20.00																		10.00					10.00							
H6360	002	0	1	18	06	H6360_002_0	6	5	Specialty Tier	1	4	100001	1	1	110100000010101000000001	31		90							2	31		90							31				31	14					842.00	25		25																					25		25																	25							25			
H6360	002	0	1	18	06	H6360_002_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		90							2	31		90							31				31	14		65.00		195.00																						65.00		130.00																		65.00								65.00				
H6360	002	0	1	18	06	H6360_002_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	31		90							2	31		90							31		31					5.00		15.00																						5.00		10.00																		5.00					5.00							
H6360	002	0	1	18	06	H6360_002_0	6	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000100	31		90							2	31		90							31		31					10.00		30.00																						10.00		20.00																		10.00					10.00					1		
H6360	002	0	1	18	06	H6360_002_0	6	6	Vaccines	3	4	000001	1	2	110000000010000000000000	31																			31					1		0.00																																												0.00										1		
H6360	006	0	1	18	06	H6360_006_0	7	3	Preferred Brand	1	3	000001		2	110100000010101000000001	31		90							2	31		90							31				31	14		45.00		135.00																						45.00		90.00																		45.00								45.00				
H6360	006	0	1	18	06	H6360_006_0	7	2	Non-Preferred Generic	1	3	000100		2	010100000010101000000100	31		90							2	31		90							31		31					17.00		51.00																						17.00		34.00																		17.00					17.00							
H6360	006	0	1	18	06	H6360_006_0	7	6	Vaccines	1	3	000001		2	110000000010000000000000	31																			31					1		0.00																																												0.00												
H6360	006	0	1	18	06	H6360_006_0	7	5	Specialty Tier	1	3	100001		1	110100000010101000000001	31		90							2	31		90							31				31	14					563.00	25		25																					25		25																	25							25			
H6360	006	0	1	18	06	H6360_006_0	7	1	Preferred Generic	1	3	001000		2	010100000010101000000100	31		90							2	31		90							31		31					6.00		18.00																						6.00		12.00																		6.00					6.00							
H6360	006	0	1	18	06	H6360_006_0	7	4	Non-Preferred Brand	1	3	100000		2	110100000010101000000001	31		90							2	31		90							31				31	14		93.00		279.00																						93.00		186.00																		93.00								93.00				
H6360	009	0	2	18	06	H6360_009_0	4	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	31		90							2	31		90							31		31					5.00		15.00																						5.00		10.00																		5.00					5.00							
H6360	009	0	2	18	06	H6360_009_0	4	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	31		90							2	31		90							31		31					10.00		30.00																						10.00		20.00																		10.00					10.00							
H6360	009	0	2	18	06	H6360_009_0	4	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		90							2	31		90							31				31	14		45.00		135.00																						45.00		90.00																		45.00								45.00				
H6360	009	0	2	18	06	H6360_009_0	4	5	Specialty Tier	1	4	100001	1	1	110100000010101000000001	31		90							2	31		90							31				31	14					541.00	25		25																					25		25																	25							25			
H6360	009	0	2	18	06	H6360_009_0	4	6	Vaccines	1	4	000001	1	2	110000000010000000000000	31																			31					1		0.00																																												0.00												
H6360	009	0	2	18	06	H6360_009_0	4	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	31		90							2	31		90							31		31					5.00		15.00																						5.00		10.00																		5.00					5.00					1		
H6360	009	0	2	18	06	H6360_009_0	4	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000100	31		90							2	31		90							31		31					10.00		30.00																						10.00		20.00																		10.00					10.00					1		
H6360	009	0	2	18	06	H6360_009_0	4	6	Vaccines	3	4	000001	1	2	110000000010000000000000	31																			31					1		0.00																																												0.00										1		
H6360	009	0	2	18	06	H6360_009_0	4	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		90							2	31		90							31				31	14		65.00		195.00																						65.00		130.00																		65.00								65.00				
H6360	010	0	1	18	06	H6360_010_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	31		90							2	31		90							31		31					8.00		24.00																						8.00		16.00																		8.00					8.00							
H6360	010	0	1	18	06	H6360_010_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	31		90							2	31		90							31		31					24.00		72.00																						24.00		48.00																		24.00					24.00							
H6360	010	0	1	18	06	H6360_010_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		90							2	31		90							31				31	14		45.00		135.00																						45.00		90.00																		45.00								45.00				
H6360	010	0	1	18	06	H6360_010_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		90							2	31		90							31				31	14		95.00		285.00																						95.00		190.00																		95.00								95.00				
H6360	010	0	1	18	06	H6360_010_0	6	5	Specialty Tier	1	4	100001	1	1	110100000010101000000001	31		90							2	31		90							31				31	14					900.00	25		25																					25		25																	25							25			
H6360	010	0	1	18	06	H6360_010_0	6	6	Vaccines	3	4	000001	1	2	110000000010000000000001	31																			31				31	1		0.00																																												0.00								0.00		1		
H6360	010	0	1	18	06	H6360_010_0	6	6	Vaccines	1	4	000001	1	2	110000000010000000000001	31																			31				31	1		0.00																																												0.00								0.00				
H6411	002	0	1	04	01	H6411_002_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00				
H6411	002	0	1	04	01	H6411_002_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H6411	002	0	1	04	01	H6411_002_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					954.00	33																														33							33					33				33			33	2	3	
H6411	002	0	1	04	01	H6411_002_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00		2	3	
H6411	002	0	1	04	01	H6411_002_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		42.00		126.00																													42.00		116.00					42.00		126.00				42.00					42.00			42.00		2	2	
H6411	002	0	1	04	01	H6411_002_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H6411	002	0	1	04	01	H6411_002_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00		2	3	1
H6411	002	0	1	04	01	H6411_002_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					854.00	33																														33							33					33				33			33			
H6411	002	0	1	04	01	H6411_002_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00				
H6411	002	0	1	04	01	H6411_002_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		42.00		126.00																													42.00		116.00					42.00		126.00				42.00					42.00			42.00				
H6411	007	0	1	04	01	H6411_007_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H6411	007	0	1	04	01	H6411_007_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		75.00		225.00																													75.00		215.00					75.00		225.00				75.00					75.00			75.00		2	3	
H6411	007	0	1	04	01	H6411_007_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H6411	007	0	1	04	01	H6411_007_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H6411	007	0	1	04	01	H6411_007_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					691.00	33																														33							33					33				33			33	2	3	
H6411	007	0	1	04	01	H6411_007_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					631.00	33																														33							33					33				33			33			
H6411	007	0	1	04	01	H6411_007_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		75.00		225.00																													75.00		215.00					75.00		225.00				75.00					75.00			75.00				
H6411	007	0	1	04	01	H6411_007_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H6411	007	0	1	04	01	H6411_007_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H6411	007	0	1	04	01	H6411_007_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H6528	001	0	1	04	01	H6528_001_0	5	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					6.00	12.00	18.00																						6.00	12.00	15.00																		6.00					6.00							
H6528	001	0	1	04	01	H6528_001_0	5	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
H6528	001	0	1	04	01	H6528_001_0	5	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
H6528	001	0	1	04	01	H6528_001_0	5	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					1131.00	33	33	33																					33	33	33																	33				33			33			
H6528	005	0	1	04	01	H6528_005_0	5	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					832.00	33	33	33																					33	33	33																	33				33			33			
H6528	005	0	1	04	01	H6528_005_0	5	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
H6528	005	0	1	04	01	H6528_005_0	5	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					6.00	12.00	18.00																						6.00	12.00	15.00																		6.00					6.00							
H6528	005	0	1	04	01	H6528_005_0	5	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
H6528	006	0	1	04	01	H6528_006_0	5	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
H6528	006	0	1	04	01	H6528_006_0	5	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
H6528	006	0	1	04	01	H6528_006_0	5	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					6.00	12.00	18.00																						6.00	12.00	15.00																		6.00					6.00							
H6528	006	0	1	04	01	H6528_006_0	5	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					630.00	33	33	33																					33	33	33																	33				33			33			
H6528	007	0	1	04	01	H6528_007_0	4	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					6.00	12.00	18.00																						6.00	12.00	15.00																		6.00					6.00							
H6528	007	0	1	04	01	H6528_007_0	4	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
H6528	007	0	1	04	01	H6528_007_0	4	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
H6528	007	0	1	04	01	H6528_007_0	4	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					797.00	33	33	33																					33	33	33																	33				33			33			
H6528	010	0	1	04	01	H6528_010_0	3	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					6.00	12.00	18.00																						6.00	12.00	15.00																		6.00					6.00							
H6528	010	0	1	04	01	H6528_010_0	3	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
H6528	010	0	1	04	01	H6528_010_0	3	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					885.00	33	33	33																					33	33	33																	33				33			33			
H6528	010	0	1	04	01	H6528_010_0	3	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
H6528	013	0	1	04	01	H6528_013_0	3	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
H6528	013	0	1	04	01	H6528_013_0	3	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
H6528	013	0	1	04	01	H6528_013_0	3	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					6.00	12.00	18.00																						6.00	12.00	15.00																		6.00					6.00							
H6528	013	0	1	04	01	H6528_013_0	3	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					903.00	33	33	33																					33	33	33																	33				33			33			
H6528	016	0	1	04	01	H6528_016_0	3	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
H6528	016	0	1	04	01	H6528_016_0	3	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
H6528	016	0	1	04	01	H6528_016_0	3	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					6.00	12.00	18.00																						6.00	12.00	15.00																		6.00					6.00							
H6528	016	0	1	04	01	H6528_016_0	3	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					890.00	33	33	33																					33	33	33																	33				33			33			
H6528	019	0	1	04	01	H6528_019_0	3	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					6.00	12.00	18.00																						6.00	12.00	15.00																		6.00					6.00							
H6528	019	0	1	04	01	H6528_019_0	3	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
H6528	019	0	1	04	01	H6528_019_0	3	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
H6528	019	0	1	04	01	H6528_019_0	3	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					886.00	33	33	33																					33	33	33																	33				33			33			
H6528	022	0	1	04	01	H6528_022_0	3	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					6.00	12.00	18.00																						6.00	12.00	15.00																		6.00					6.00							
H6528	022	0	1	04	01	H6528_022_0	3	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
H6528	022	0	1	04	01	H6528_022_0	3	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
H6528	022	0	1	04	01	H6528_022_0	3	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					864.00	33	33	33																					33	33	33																	33				33			33			
H6528	024	0	1	04	01	H6528_024_0	3	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					6.00	12.00	18.00																						6.00	12.00	15.00																		6.00					6.00							
H6528	024	0	1	04	01	H6528_024_0	3	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
H6528	024	0	1	04	01	H6528_024_0	3	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
H6528	024	0	1	04	01	H6528_024_0	3	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					882.00	33	33	33																					33	33	33																	33				33			33			
H6528	026	0	1	04	01	H6528_026_0	3	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					6.00	12.00	18.00																						6.00	12.00	15.00																		6.00					6.00							
H6528	026	0	1	04	01	H6528_026_0	3	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
H6528	026	0	1	04	01	H6528_026_0	3	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
H6528	026	0	1	04	01	H6528_026_0	3	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					869.00	33	33	33																					33	33	33																	33				33			33			
H6528	028	0	1	04	01	H6528_028_0	3	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					6.00	12.00	18.00																						6.00	12.00	15.00																		6.00					6.00							
H6528	028	0	1	04	01	H6528_028_0	3	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
H6528	028	0	1	04	01	H6528_028_0	3	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
H6528	028	0	1	04	01	H6528_028_0	3	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					866.00	33	33	33																					33	33	33																	33				33			33			
H6609	001	0	1	04	01	H6609_001_0	6	1	Preferred Generic	1	3	001010		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00				
H6609	001	0	1	04	01	H6609_001_0	6	2	Non-Preferred Generic	1	3	000101		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H6609	001	0	1	04	01	H6609_001_0	6	3	Preferred Brand	1	3	000101		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H6609	001	0	1	04	01	H6609_001_0	6	4	Non-Preferred Brand	1	3	110000		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00				
H6609	001	0	1	04	01	H6609_001_0	6	5	Specialty Tier	1	3	010010		1	110000000010000100100101	30													30			30			30		31		31	14					714.00	28																														28							28					28				28			28			
H6609	003	0	1	04	01	H6609_003_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H6609	003	0	1	04	01	H6609_003_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H6609	003	0	1	04	01	H6609_003_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H6609	003	0	1	04	01	H6609_003_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					992.00	33																														33							33					33				33			33	2	3	
H6609	003	0	1	04	01	H6609_003_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H6609	003	0	1	04	01	H6609_003_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					924.00	33																														33							33					33				33			33			
H6609	003	0	1	04	01	H6609_003_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H6609	003	0	1	04	01	H6609_003_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H6609	003	0	1	04	01	H6609_003_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H6609	003	0	1	04	01	H6609_003_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H6609	005	0	1	04	01	H6609_005_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00		2	3	1
H6609	005	0	1	04	01	H6609_005_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					738.00	33																														33							33					33				33			33			
H6609	005	0	1	04	01	H6609_005_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H6609	005	0	1	04	01	H6609_005_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H6609	005	0	1	04	01	H6609_005_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					897.00	33																														33							33					33				33			33	2	3	
H6609	005	0	1	04	01	H6609_005_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		18.00		54.00																													0.00		0.00					18.00		54.00				18.00					18.00			18.00		2	2	
H6609	005	0	1	04	01	H6609_005_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00				
H6609	005	0	1	04	01	H6609_005_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		18.00		54.00																													0.00		0.00					18.00		54.00				18.00					18.00			18.00				
H6609	005	0	1	04	01	H6609_005_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H6609	005	0	1	04	01	H6609_005_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H6609	009	0	1	04	01	H6609_009_0	6	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		39.00		117.00																													39.00		107.00					39.00		117.00				39.00					39.00			39.00		2	2	
H6609	009	0	1	04	01	H6609_009_0	6	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H6609	009	0	1	04	01	H6609_009_0	6	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					906.00	33																														33							33					33				33			33	2	3	
H6609	009	0	1	04	01	H6609_009_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H6609	009	0	1	04	01	H6609_009_0	6	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					896.00	33																														33							33					33				33			33			
H6609	009	0	1	04	01	H6609_009_0	6	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H6609	009	0	1	04	01	H6609_009_0	6	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		39.00		117.00																													39.00		107.00					39.00		117.00				39.00					39.00			39.00				
H6609	009	0	1	04	01	H6609_009_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H6609	011	0	1	04	01	H6609_011_0	7	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		39.00		117.00																													39.00		107.00					39.00		117.00				39.00					39.00			39.00		2	2	
H6609	011	0	1	04	01	H6609_011_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H6609	011	0	1	04	01	H6609_011_0	7	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1074.00	33																														33							33					33				33			33			
H6609	011	0	1	04	01	H6609_011_0	7	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H6609	011	0	1	04	01	H6609_011_0	7	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		39.00		117.00																													39.00		107.00					39.00		117.00				39.00					39.00			39.00				
H6609	011	0	1	04	01	H6609_011_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H6609	011	0	1	04	01	H6609_011_0	7	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H6609	011	0	1	04	01	H6609_011_0	7	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1231.00	33																														33							33					33				33			33	2	3	
H6609	013	0	1	04	01	H6609_013_0	5	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H6609	013	0	1	04	01	H6609_013_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H6609	013	0	1	04	01	H6609_013_0	5	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					807.00	33																														33							33					33				33			33			
H6609	013	0	1	04	01	H6609_013_0	5	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H6609	013	0	1	04	01	H6609_013_0	5	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H6609	013	0	1	04	01	H6609_013_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H6609	013	0	1	04	01	H6609_013_0	5	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H6609	013	0	1	04	01	H6609_013_0	5	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					853.00	33																														33							33					33				33			33	2	3	
H6609	017	0	1	04	01	H6609_017_0	4	3	Preferred Brand	1	3	000101		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H6609	017	0	1	04	01	H6609_017_0	4	2	Non-Preferred Generic	1	3	000101		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H6609	017	0	1	04	01	H6609_017_0	4	1	Preferred Generic	1	3	001010		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H6609	017	0	1	04	01	H6609_017_0	4	5	Specialty Tier	1	3	010010		1	110000000010000100100101	30													30			30			30		31		31	14					1119.00	25																														25							25					25				25			25			
H6609	017	0	1	04	01	H6609_017_0	4	4	Non-Preferred Brand	1	3	110000		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H6609	019	0	1	04	01	H6609_019_0	4	2	Non-Preferred Generic	3	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										3.00		9.00						11.00		33.00													0.00		0.00					11.00		33.00				11.00					11.00			11.00		2	3	
H6609	019	0	1	04	01	H6609_019_0	4	3	Preferred Brand	3	4	000101	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													20.00	17		17					31.00	25		25												17		17					25		25			25				25			25	2	2	
H6609	019	0	1	04	01	H6609_019_0	4	4	Non-Preferred Brand	3	4	110000	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													119.00	30		30					121.00	50		50												30		30					50		50			50				50			50	2	3	
H6609	019	0	1	04	01	H6609_019_0	4	5	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													635.00	25							645.00	25														25							25					25				25			25			
H6609	019	0	1	04	01	H6609_019_0	4	4	Non-Preferred Brand	1	4	110000	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													92.00	30		30					93.00	50		50												30		30					50		50			50				50			50			
H6609	019	0	1	04	01	H6609_019_0	4	3	Preferred Brand	1	4	000101	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													15.00	17		17					23.00	25		25												17		17					25		25			25				25			25			
H6609	019	0	1	04	01	H6609_019_0	4	5	Specialty Tier	3	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													716.00	25							727.00	25														25							25					25				25			25	2	3	
H6609	019	0	1	04	01	H6609_019_0	4	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										1.00		3.00						8.00		24.00													0.00		0.00					8.00		24.00				8.00					8.00			8.00				
H6609	019	0	1	04	01	H6609_019_0	4	2	Non-Preferred Generic	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										3.00		9.00						11.00		33.00													0.00		0.00					11.00		33.00				11.00					11.00			11.00				
H6609	022	0	1	04	01	H6609_022_0	9	3	Preferred Brand	3	4	000101	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													23.00	15		15					40.00	25		25												15		15					25		25			25				25			25	2	2	
H6609	022	0	1	04	01	H6609_022_0	9	4	Non-Preferred Brand	3	4	110000	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													154.00	25		25					157.00	30		30												25		25					30		30			30				30			30	2	3	
H6609	022	0	1	04	01	H6609_022_0	9	2	Non-Preferred Generic	3	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										3.00		9.00						9.00		27.00													0.00		0.00					9.00		27.00				9.00					9.00			9.00		2	3	
H6609	022	0	1	04	01	H6609_022_0	9	5	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													586.00	25							594.00	25														25							25					25				25			25			
H6609	022	0	1	04	01	H6609_022_0	9	4	Non-Preferred Brand	1	4	110000	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													104.00	25		25					105.00	30		30												25		25					30		30			30				30			30			
H6609	022	0	1	04	01	H6609_022_0	9	3	Preferred Brand	1	4	000101	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													16.00	15		15					28.00	25		25												15		15					25		25			25				25			25			
H6609	022	0	1	04	01	H6609_022_0	9	2	Non-Preferred Generic	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										3.00		9.00						9.00		27.00													0.00		0.00					9.00		27.00				9.00					9.00			9.00				
H6609	022	0	1	04	01	H6609_022_0	9	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										1.00		3.00						6.00		18.00													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H6609	022	0	1	04	01	H6609_022_0	9	5	Specialty Tier	3	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													676.00	25							686.00	25														25							25					25				25			25	2	3	
H6609	029	0	1	04	01	H6609_029_0	7	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H6609	029	0	1	04	01	H6609_029_0	7	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		35.00		105.00																													35.00		95.00					35.00		105.00				35.00					35.00			35.00		2	2	
H6609	029	0	1	04	01	H6609_029_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H6609	029	0	1	04	01	H6609_029_0	7	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					741.00	33																														33							33					33				33			33			
H6609	029	0	1	04	01	H6609_029_0	7	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H6609	029	0	1	04	01	H6609_029_0	7	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		35.00		105.00																													35.00		95.00					35.00		105.00				35.00					35.00			35.00				
H6609	029	0	1	04	01	H6609_029_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H6609	029	0	1	04	01	H6609_029_0	7	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					819.00	33																														33							33					33				33			33	2	3	
H6609	051	0	1	04	01	H6609_051_0	4	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H6609	051	0	1	04	01	H6609_051_0	4	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		89.00		267.00																													89.00		257.00					89.00		267.00				89.00					89.00			89.00		2	3	
H6609	051	0	1	04	01	H6609_051_0	4	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					672.00	33																														33							33					33				33			33	2	3	
H6609	051	0	1	04	01	H6609_051_0	4	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00				
H6609	051	0	1	04	01	H6609_051_0	4	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H6609	051	0	1	04	01	H6609_051_0	4	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H6609	051	0	1	04	01	H6609_051_0	4	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		89.00		267.00																													89.00		257.00					89.00		267.00				89.00					89.00			89.00				
H6609	051	0	1	04	01	H6609_051_0	4	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					597.00	33																														33							33					33				33			33			
H6609	051	0	1	04	01	H6609_051_0	4	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00		2	3	1
H6609	051	0	1	04	01	H6609_051_0	4	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H6609	060	0	1	04	01	H6609_060_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H6609	060	0	1	04	01	H6609_060_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H6609	060	0	1	04	01	H6609_060_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H6609	060	0	1	04	01	H6609_060_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H6609	060	0	1	04	01	H6609_060_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					793.00	33																														33							33					33				33			33			
H6609	060	0	1	04	01	H6609_060_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H6609	060	0	1	04	01	H6609_060_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H6609	060	0	1	04	01	H6609_060_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H6609	060	0	1	04	01	H6609_060_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H6609	060	0	1	04	01	H6609_060_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					893.00	33																														33							33					33				33			33	2	3	
H6609	062	0	1	04	01	H6609_062_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H6609	062	0	1	04	01	H6609_062_0	5	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1298.00	33																														33							33					33				33			33	2	3	
H6609	062	0	1	04	01	H6609_062_0	5	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H6609	062	0	1	04	01	H6609_062_0	5	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H6609	062	0	1	04	01	H6609_062_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H6609	062	0	1	04	01	H6609_062_0	5	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1099.00	33																														33							33					33				33			33			
H6609	062	0	1	04	01	H6609_062_0	5	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H6609	062	0	1	04	01	H6609_062_0	5	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H6609	063	0	1	04	01	H6609_063_0	5	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H6609	063	0	1	04	01	H6609_063_0	5	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H6609	063	0	1	04	01	H6609_063_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H6609	063	0	1	04	01	H6609_063_0	5	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					919.00	33																														33							33					33				33			33	2	3	
H6609	063	0	1	04	01	H6609_063_0	5	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H6609	063	0	1	04	01	H6609_063_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H6609	063	0	1	04	01	H6609_063_0	5	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					821.00	33																														33							33					33				33			33			
H6609	063	0	1	04	01	H6609_063_0	5	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H6609	065	0	1	04	01	H6609_065_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H6609	065	0	1	04	01	H6609_065_0	5	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					821.00	33																														33							33					33				33			33			
H6609	065	0	1	04	01	H6609_065_0	5	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H6609	065	0	1	04	01	H6609_065_0	5	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H6609	065	0	1	04	01	H6609_065_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H6609	065	0	1	04	01	H6609_065_0	5	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					919.00	33																														33							33					33				33			33	2	3	
H6609	065	0	1	04	01	H6609_065_0	5	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H6609	065	0	1	04	01	H6609_065_0	5	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H6609	066	0	1	04	01	H6609_066_0	5	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H6609	066	0	1	04	01	H6609_066_0	5	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H6609	066	0	1	04	01	H6609_066_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H6609	066	0	1	04	01	H6609_066_0	5	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					821.00	33																														33							33					33				33			33			
H6609	066	0	1	04	01	H6609_066_0	5	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H6609	066	0	1	04	01	H6609_066_0	5	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H6609	066	0	1	04	01	H6609_066_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H6609	066	0	1	04	01	H6609_066_0	5	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					919.00	33																														33							33					33				33			33	2	3	
H6609	067	0	1	04	01	H6609_067_0	5	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					774.00	33																														33							33					33				33			33	2	3	
H6609	067	0	1	04	01	H6609_067_0	5	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H6609	067	0	1	04	01	H6609_067_0	5	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H6609	067	0	1	04	01	H6609_067_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H6609	067	0	1	04	01	H6609_067_0	5	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					665.00	33																														33							33					33				33			33			
H6609	067	0	1	04	01	H6609_067_0	5	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H6609	067	0	1	04	01	H6609_067_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H6609	067	0	1	04	01	H6609_067_0	5	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H6609	068	0	1	04	01	H6609_068_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H6609	068	0	1	04	01	H6609_068_0	5	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H6609	068	0	1	04	01	H6609_068_0	5	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H6609	068	0	1	04	01	H6609_068_0	5	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					789.00	33																														33							33					33				33			33			
H6609	068	0	1	04	01	H6609_068_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H6609	068	0	1	04	01	H6609_068_0	5	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H6609	068	0	1	04	01	H6609_068_0	5	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H6609	068	0	1	04	01	H6609_068_0	5	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					888.00	33																														33							33					33				33			33	2	3	
H6609	072	0	1	04	01	H6609_072_0	5	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H6609	072	0	1	04	01	H6609_072_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H6609	072	0	1	04	01	H6609_072_0	5	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					875.00	33																														33							33					33				33			33	2	3	
H6609	072	0	1	04	01	H6609_072_0	5	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H6609	072	0	1	04	01	H6609_072_0	5	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H6609	072	0	1	04	01	H6609_072_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H6609	072	0	1	04	01	H6609_072_0	5	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					780.00	33																														33							33					33				33			33			
H6609	072	0	1	04	01	H6609_072_0	5	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H6622	001	0	1	01	01	H6622_001_0	6	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H6622	001	0	1	01	01	H6622_001_0	6	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H6622	001	0	1	01	01	H6622_001_0	6	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1105.00	33																														33							33					33				33			33	2	3	
H6622	001	0	1	01	01	H6622_001_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00		2	3	1
H6622	001	0	1	01	01	H6622_001_0	6	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1048.00	33																														33							33					33				33			33			
H6622	001	0	1	01	01	H6622_001_0	6	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H6622	001	0	1	01	01	H6622_001_0	6	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H6622	001	0	1	01	01	H6622_001_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H6622	002	0	1	01	01	H6622_002_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	3	1
H6622	002	0	1	01	01	H6622_002_0	6	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H6622	002	0	1	01	01	H6622_002_0	6	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H6622	002	0	1	01	01	H6622_002_0	6	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1269.00	33																														33							33					33				33			33	2	3	
H6622	002	0	1	01	01	H6622_002_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H6622	002	0	1	01	01	H6622_002_0	6	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H6622	002	0	1	01	01	H6622_002_0	6	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H6622	002	0	1	01	01	H6622_002_0	6	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1028.00	33																														33							33					33				33			33			
H6622	003	0	1	02	01	H6622_003_0	7	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H6622	003	0	1	02	01	H6622_003_0	7	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H6622	003	0	1	02	01	H6622_003_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H6622	003	0	1	02	01	H6622_003_0	7	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					759.00	33																														33							33					33				33			33			
H6622	003	0	1	02	01	H6622_003_0	7	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H6622	003	0	1	02	01	H6622_003_0	7	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					869.00	33																														33							33					33				33			33	2	3	
H6622	003	0	1	02	01	H6622_003_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H6622	003	0	1	02	01	H6622_003_0	7	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H6642	001	0	1	01	01	H6642_001_0	11	5	Specialty Tier	1	4	010010	1	1	110100000010111000000111	31		90							1	31	60	90							31		34	14	34	14					250.00	33		33																					33	33	33																	33				33			33			
H6642	001	0	1	01	01	H6642_001_0	11	4	Non-Preferred Brand	1	4	100000	1	2	110100000010111000000001	31		90							1	31	60	90							31				34	14		60.00		180.00																						60.00	120.00	180.00																		60.00								60.00				
H6642	001	0	1	01	01	H6642_001_0	11	3	Preferred Brand	1	4	010001	1	2	110100000010111000000111	31		90							1	31	60	90							31		34	14	34	14		15.00		45.00																						15.00	30.00	45.00																		15.00					15.00			15.00				
H6642	001	0	1	01	01	H6642_001_0	11	1	Preferred Generic	1	4	001000	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14				0.00		0.00																						0.00	0.00	0.00																		0.00					0.00							
H6642	001	0	1	01	01	H6642_001_0	11	2	Non-Preferred Generic	1	4	000100	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14				0.00		0.00																						0.00	0.00	0.00																		0.00					0.00							
H6642	007	0	1	01	01	H6642_007_0	10	5	Specialty Tier	1	4	010010	1	1	110100000010111000000111	31		90							1	31	60	90							31		34	14	34	14					100.00	33		33																					33	33	33																	33				33			33			
H6642	007	0	1	01	01	H6642_007_0	10	4	Non-Preferred Brand	1	4	100000	1	2	110100000010111000000001	31		90							1	31	60	90							31				34	14		95.00		285.00																						95.00	190.00	285.00																		95.00								95.00				
H6642	007	0	1	01	01	H6642_007_0	10	3	Preferred Brand	1	4	010001	1	2	110100000010111000000111	31		90							1	31	60	90							31		34	14	34	14		45.00		135.00																						45.00	90.00	135.00																		45.00					45.00			45.00				
H6642	007	0	1	01	01	H6642_007_0	10	2	Non-Preferred Generic	1	4	000100	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14				5.00		15.00																						5.00	10.00	10.00																		5.00					5.00							
H6642	007	0	1	01	01	H6642_007_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14				0.00		0.00																						0.00	0.00	0.00																		0.00					0.00							
H6642	007	0	1	01	01	H6642_007_0	10	1	Preferred Generic	3	4	001000	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14				0.00		0.00																						0.00	0.00	0.00																		0.00					0.00					1		
H6642	007	0	1	01	01	H6642_007_0	10	2	Non-Preferred Generic	3	4	000100	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14				5.00		15.00																						5.00	10.00	10.00																		5.00					5.00					1		
H6705	001	0	1	01	01	H6705_001_0	8	3	Preferred Brand	1	4	010001	1	2	110100000010111000000111	31		90							1	31	60	90							31		34	14	34	14		45.00		135.00																						45.00	90.00	135.00																		45.00					45.00			45.00				
H6705	001	0	1	01	01	H6705_001_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14				0.00		0.00																						0.00	0.00	0.00																		0.00					0.00							
H6705	001	0	1	01	01	H6705_001_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14				4.00		12.00																						4.00	8.00	8.00																		4.00					4.00							
H6705	001	0	1	01	01	H6705_001_0	8	4	Non-Preferred Brand	1	4	100000	1	2	110100000010111000000001	31		90							1	31	60	90							31				34	14		95.00		285.00																						95.00	190.00	285.00																		95.00								95.00				
H6705	001	0	1	01	01	H6705_001_0	8	5	Specialty Tier	1	4	010010	1	1	110100000010111000000111	31		90							1	31	60	90							31		34	14	34	14					200.00	33		33																					33	33	33																	33				33			33			
H6705	003	0	1	01	01	H6705_003_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000010111000000001	31		90							1	31	60	90							31				34	14		95.00		285.00																						95.00	190.00	285.00																		95.00								95.00				
H6705	003	0	1	01	01	H6705_003_0	9	1	Preferred Generic	3	4	001000	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14				0.00		0.00																						0.00	0.00	0.00																		0.00					0.00					1		
H6705	003	0	1	01	01	H6705_003_0	9	2	Non-Preferred Generic	3	4	000100	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14				5.00		10.00																						5.00	10.00	10.00																		5.00					5.00					1		
H6705	003	0	1	01	01	H6705_003_0	9	5	Specialty Tier	1	4	010010	1	1	110100000010111000000111	31		90							1	31	60	90							31		34	14	34	14					200.00	33		33																					33	33	33																	33				33			33			
H6705	003	0	1	01	01	H6705_003_0	9	3	Preferred Brand	1	4	010001	1	2	110100000010111000000111	31		90							1	31	60	90							31		34	14	34	14		45.00		135.00																						45.00	90.00	135.00																		45.00					45.00			45.00				
H6705	003	0	1	01	01	H6705_003_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14				5.00		15.00																						5.00	10.00	10.00																		5.00					5.00							
H6705	003	0	1	01	01	H6705_003_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14				0.00		0.00																						0.00	0.00	0.00																		0.00					0.00							
H6743	001	0	1	04	01	H6743_001_0	8	4	Specialty Tier	1	4	100100	1	1	110100000010101000000111	31		90							1	31		90							31		31	14	31	14					200.00	33		33																					33		33																	33				33			33			
H6743	001	0	1	04	01	H6743_001_0	8	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		95.00		190.00																						95.00		190.00																		95.00								95.00				
H6743	001	0	1	04	01	H6743_001_0	8	1	Generic	1	4	010001	1	2	110100000010101000000111	31		90							1	31		90							31		31	14	31	14		10.00		20.00																						10.00		20.00																		10.00					10.00			10.00				
H6743	001	0	1	04	01	H6743_001_0	8	2	Preferred Brand	1	4	000101	1	2	110100000010101000000111	31		90							1	31		90							31		31	14	31	14		45.00		90.00																						45.00		90.00																		45.00					45.00			45.00				
H6743	003	0	1	04	01	H6743_003_0	8	1	Generic	1	4	010001	1	2	110100000010101000000111	31		90							1	31		90							31		31	14	31	14		6.00		12.00																						6.00		12.00																		6.00					6.00			6.00				
H6743	003	0	1	04	01	H6743_003_0	8	2	Preferred Brand	1	4	000101	1	2	110100000010101000000111	31		90							1	31		90							31		31	14	31	14		40.00		80.00																						40.00		80.00																		40.00					40.00			40.00				
H6743	003	0	1	04	01	H6743_003_0	8	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		85.00		170.00																						85.00		170.00																		85.00								85.00				
H6743	003	0	1	04	01	H6743_003_0	8	4	Specialty Tier	1	4	100100	1	1	110100000010101000000111	31		90							1	31		90							31		31	14	31	14					200.00	33		33																					33		33																	33				33			33			
H6743	004	0	1	04	01	H6743_004_0	8	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		75.00		150.00																						75.00		150.00																		75.00								75.00				
H6743	004	0	1	04	01	H6743_004_0	8	2	Preferred Brand	1	4	000101	1	2	110100000010101000000111	31		90							1	31		90							31		31	14	31	14		35.00		70.00																						35.00		70.00																		35.00					35.00			35.00				
H6743	004	0	1	04	01	H6743_004_0	8	1	Generic	1	4	010010	1	2	110100000010101000000111	31		90							1	31		90							31		31	14	31	14		4.00		8.00																						4.00		8.00																		4.00					4.00			4.00				
H6743	004	0	1	04	01	H6743_004_0	8	4	Specialty Tier	1	4	100100	1	1	110100000010101000000111	31		90							1	31		90							31		31	14	31	14					200.00	33		33																					33		33																	33				33			33			
H6743	005	0	1	04	01	H6743_005_0	9	4	Specialty Tier	1	4	100100	1	1	110100000010101000000111	31		90							1	31		90							31		31	14	31	14					200.00	33		33																					33		33																	33				33			33			
H6743	005	0	1	04	01	H6743_005_0	9	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		75.00		150.00																						75.00		150.00																		75.00								75.00				
H6743	005	0	1	04	01	H6743_005_0	9	2	Preferred Brand	1	4	000101	1	2	110100000010101000000111	31		90							1	31		90							31		31	14	31	14		35.00		70.00																						35.00		70.00																		35.00					35.00			35.00				
H6743	005	0	1	04	01	H6743_005_0	9	1	Generic	1	4	010010	1	2	110100000010101000000111	31		90							1	31		90							31		31	14	31	14		4.00		8.00																						4.00		8.00																		4.00					4.00			4.00				
H6743	007	0	1	04	01	H6743_007_0	8	1	Generic	1	4	010001	1	2	110100000010101000000111	31		90							1	31		90							31		31	14	31	14		10.00		20.00																						10.00		20.00																		10.00					10.00			10.00				
H6743	007	0	1	04	01	H6743_007_0	8	4	Specialty Tier	1	4	100100	1	1	110100000010101000000111	31		90							1	31		90							31		31	14	31	14					200.00	33		33																					33		33																	33				33			33			
H6743	007	0	1	04	01	H6743_007_0	8	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		95.00		190.00																						95.00		190.00																		95.00								95.00				
H6743	007	0	1	04	01	H6743_007_0	8	2	Preferred Brand	1	4	000101	1	2	110100000010101000000111	31		90							1	31		90							31		31	14	31	14		45.00		90.00																						45.00		90.00																		45.00					45.00			45.00				
H6786	001	0	1	04	01	H6786_001_0	13	5	Injectable Drugs	1	3	010010		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H6786	001	0	1	04	01	H6786_001_0	13	4	Non-Preferred Brand	1	3	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		80.00	160.00	240.00																						80.00	160.00	200.00																		80.00					80.00			80.00				
H6786	001	0	1	04	01	H6786_001_0	13	3	Preferred Brand	1	3	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		39.00	78.00	117.00																						39.00	78.00	97.50																		39.00					39.00			39.00				
H6786	001	0	1	04	01	H6786_001_0	13	2	Non-Preferred Generic	1	3	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				10.00	20.00	30.00																						10.00	20.00	15.00																		10.00					10.00							
H6786	001	0	1	04	01	H6786_001_0	13	6	Specialty Tier	1	3	010010		1	110000000010100000000111	30										30									30		34	14	34	14					860.00	33																							33																			33				33			33			
H6786	001	0	1	04	01	H6786_001_0	13	1	Preferred Generic	1	3	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				5.00	10.00	15.00																						5.00	10.00	7.50																		5.00					5.00							
H6801	002	0	1	01	01	H6801_002_0	11	4	Non-Preferred Brand	1	4	100000	1	2	110100000001001000000001	30		90							1			90								29			31	2		90.00		270.00																								270.00																			90.00							90.00				
H6801	002	0	1	01	01	H6801_002_0	11	3	Preferred Brand	1	4	000001	1	2	110100000001001000000001	30		90							1			90								29			31	2		32.00		96.00																								96.00																			32.00							32.00				
H6801	002	0	1	01	01	H6801_002_0	11	2	Non-Preferred Generic	1	4	000100	1	2	010100000001001000000100	30		90							1			90								29	31					5.00		15.00																								15.00																			5.00				5.00							
H6801	002	0	1	01	01	H6801_002_0	11	1	Preferred Generic	1	4	001000	1	2	010100000001001000000100	30		90							1			90								29	31					0.00		0.00																								0.00																			0.00				0.00							
H6801	002	0	1	01	01	H6801_002_0	11	1	Preferred Generic	3	4	001000	1	2	010100000001001000000100	30		90							1			90								29	31					0.00		0.00																								0.00																			0.00				0.00					1		
H6801	002	0	1	01	01	H6801_002_0	11	2	Non-Preferred Generic	3	4	000100	1	2	010100000001001000000100	30		90							1			90								29	31					5.00		15.00																								15.00																			5.00				5.00					1		
H6801	002	0	1	01	01	H6801_002_0	11	5	Specialty Tier	1	4	000001	1	1	110100000001001000000001	30		90							1			90								29			31	2					33.00	33		33																							33																		33						33			
H6801	004	0	1	01	01	H6801_004_0	11	3	Preferred Brand	1	4	000001	1	2	110100000001001000000001	30		90							1			90								29			31	2		30.00		90.00																								90.00																			30.00							30.00				
H6801	004	0	1	01	01	H6801_004_0	11	4	Non-Preferred Brand	1	4	100000	1	2	110100000001001000000001	30		90							1			90								29			31	2		70.00		210.00																								210.00																			70.00							70.00				
H6801	004	0	1	01	01	H6801_004_0	11	1	Preferred Generic	3	4	001000	1	2	010100000001001000000100	30		90							1			90								29	31					0.00		0.00																								0.00																			0.00				0.00					1		
H6801	004	0	1	01	01	H6801_004_0	11	2	Non-Preferred Generic	3	4	000100	1	2	010100000001001000000100	30		90							1			90								29	31					4.00		12.00																								12.00																			4.00				4.00					1		
H6801	004	0	1	01	01	H6801_004_0	11	1	Preferred Generic	1	4	001000	1	2	010100000001001000000100	30		90							1			90								29	31					0.00		0.00																								0.00																			0.00				0.00							
H6801	004	0	1	01	01	H6801_004_0	11	2	Non-Preferred Generic	1	4	000100	1	2	010100000001001000000100	30		90							1			90								29	31					4.00		12.00																								12.00																			4.00				4.00							
H6801	004	0	1	01	01	H6801_004_0	11	5	Specialty Tier	1	4	000001	1	1	110100000001001000000001	30		90							1			90								29			31	2					33.00	33		33																							33																		33						33			
H6815	001	0	1	01	01	H6815_001_0	6	5	Specialty Tier	1	4	010010	1	1	111100000010000111111111	30	60	90							1				30	60	90	30	60	90	30		34	14	34	14					479.00	33	33	33																												33	33	33					33	33	33			33				33			33			
H6815	001	0	1	01	01	H6815_001_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		95.00	190.00	285.00																													95.00	190.00	238.00					95.00	190.00	285.00				95.00								95.00				
H6815	001	0	1	01	01	H6815_001_0	6	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		38.00	76.00	114.00																													38.00	76.00	76.00					38.00	76.00	114.00				38.00								38.00				
H6815	001	0	1	01	01	H6815_001_0	6	1	Preferred Generic	1	4	001000	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				0.00	0.00	0.00																													0.00	0.00	0.00					0.00	0.00	0.00				0.00					0.00							
H6815	001	0	1	01	01	H6815_001_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				20.00	40.00	60.00																													20.00	40.00	40.00					20.00	40.00	60.00				20.00					20.00							
H6815	002	0	1	01	01	H6815_002_0	6	1	Preferred Generic	1	4	001000	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				0.00	0.00	0.00																													0.00	0.00	0.00					0.00	0.00	0.00				0.00					0.00							
H6815	002	0	1	01	01	H6815_002_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		95.00	190.00	285.00																													95.00	190.00	238.00					95.00	190.00	285.00				95.00								95.00				
H6815	002	0	1	01	01	H6815_002_0	6	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							1				30	60	90	30	60	90	30				34	14		38.00	76.00	114.00																													38.00	76.00	76.00					38.00	76.00	114.00				38.00								38.00				
H6815	002	0	1	01	01	H6815_002_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111110	30	60	90							1				30	60	90	30	60	90	30		34	14				20.00	40.00	60.00																													20.00	40.00	40.00					20.00	40.00	60.00				20.00					20.00							
H6815	002	0	1	01	01	H6815_002_0	6	5	Specialty Tier	1	4	010010	1	1	111100000010000111111111	30	60	90							1				30	60	90	30	60	90	30		34	14	34	14					485.00	33	33	33																												33	33	33					33	33	33			33				33			33			
H6881	002	0	1	04	01	H6881_002_0	10	4	Specialty Tier	1	4	100100	1	1	110100000010101000000111	30		90							1	30		90							30		31	14	31	14					513.32	33		33																					33		33																	33				33			33			
H6881	002	0	1	04	01	H6881_002_0	10	1	Preferred Generic	1	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		4.00		12.00																						4.00		10.00																		4.00					4.00			4.00				
H6881	002	0	1	04	01	H6881_002_0	10	2	Preferred Brand	1	4	000101	1	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		44.00		132.00																						44.00		110.00																		44.00					44.00			44.00				
H6881	002	0	1	04	01	H6881_002_0	10	3	Non-Preferred Brand	1	4	100100	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		78.00		234.00																						78.00		195.00																		78.00					78.00			78.00				
H6900	001	0	1	04	01	H6900_001_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H6900	001	0	1	04	01	H6900_001_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H6900	001	0	1	04	01	H6900_001_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H6900	001	0	1	04	01	H6900_001_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H6900	001	0	1	04	01	H6900_001_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					821.00	33																														33							33					33				33			33			
H6900	001	0	1	04	01	H6900_001_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H6900	001	0	1	04	01	H6900_001_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H6900	001	0	1	04	01	H6900_001_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H6900	001	0	1	04	01	H6900_001_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H6900	001	0	1	04	01	H6900_001_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					929.00	33																														33							33					33				33			33	2	3	
H6900	004	0	1	04	01	H6900_004_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H6900	004	0	1	04	01	H6900_004_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H6900	004	0	1	04	01	H6900_004_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					680.00	33																														33							33					33				33			33			
H6900	004	0	1	04	01	H6900_004_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H6900	004	0	1	04	01	H6900_004_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H6900	004	0	1	04	01	H6900_004_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H6900	004	0	1	04	01	H6900_004_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H6900	004	0	1	04	01	H6900_004_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					736.00	33																														33							33					33				33			33	2	3	
H6900	004	0	1	04	01	H6900_004_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H6900	004	0	1	04	01	H6900_004_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H6900	005	0	1	04	01	H6900_005_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1101.00	33																														33							33					33				33			33	2	3	
H6900	005	0	1	04	01	H6900_005_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H6900	005	0	1	04	01	H6900_005_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H6900	005	0	1	04	01	H6900_005_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H6900	005	0	1	04	01	H6900_005_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H6900	005	0	1	04	01	H6900_005_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					976.00	33																														33							33					33				33			33			
H6900	005	0	1	04	01	H6900_005_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H6900	005	0	1	04	01	H6900_005_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H6900	005	0	1	04	01	H6900_005_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H6900	005	0	1	04	01	H6900_005_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H6900	006	0	1	04	01	H6900_006_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H6900	006	0	1	04	01	H6900_006_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H6900	006	0	1	04	01	H6900_006_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H6900	006	0	1	04	01	H6900_006_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H6900	006	0	1	04	01	H6900_006_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					787.00	33																														33							33					33				33			33			
H6900	006	0	1	04	01	H6900_006_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H6900	006	0	1	04	01	H6900_006_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H6900	006	0	1	04	01	H6900_006_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H6900	006	0	1	04	01	H6900_006_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H6900	006	0	1	04	01	H6900_006_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					886.00	33																														33							33					33				33			33	2	3	
H6900	007	0	1	04	01	H6900_007_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H6900	007	0	1	04	01	H6900_007_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H6900	007	0	1	04	01	H6900_007_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H6900	007	0	1	04	01	H6900_007_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H6900	007	0	1	04	01	H6900_007_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					920.00	33																														33							33					33				33			33	2	3	
H6900	007	0	1	04	01	H6900_007_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H6900	007	0	1	04	01	H6900_007_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H6900	007	0	1	04	01	H6900_007_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					819.00	33																														33							33					33				33			33			
H6900	007	0	1	04	01	H6900_007_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H6900	007	0	1	04	01	H6900_007_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H6923	001	0	1	01	01	H6923_001_0	6	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					7.00	14.00	21.00																													7.00	14.00	14.00					7.00	14.00	21.00					7.00				7.00							
H6923	001	0	1	01	01	H6923_001_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H6923	001	0	1	01	01	H6923_001_0	6	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					280.31	33	33	33																												33	33	33					33	33	33				33			33			33			
H6923	001	0	1	01	01	H6923_001_0	6	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H6923	001	0	1	01	01	H6923_001_0	6	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H6972	001	0	1	01	01	H6972_001_0	8	1	Preferred Generic	1	4	001010	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		2.00		6.00																						2.00		4.00																		2.00					2.00			2.00				
H6972	001	0	1	01	01	H6972_001_0	8	2	Non-Preferred Generic	1	4	000101	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		11.00		33.00																						11.00		22.00																		11.00					11.00			11.00				
H6972	001	0	1	01	01	H6972_001_0	8	3	Preferred Brand	1	4	000101	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		45.00		135.00																						45.00		112.50																		45.00					45.00			45.00				
H6972	001	0	1	01	01	H6972_001_0	8	4	Non-Preferred Brand	1	4	110000	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		95.00		285.00																						95.00		222.50																		95.00					95.00			95.00				
H6972	001	0	1	01	01	H6972_001_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					822.00	33																							33																			33				33			33			
H7002	002	0	1	04	01	H7002_002_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					706.00	33																														33							33					33				33			33	2	3	
H7002	002	0	1	04	01	H7002_002_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00		2	3	
H7002	002	0	1	04	01	H7002_002_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H7002	002	0	1	04	01	H7002_002_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H7002	002	0	1	04	01	H7002_002_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H7002	002	0	1	04	01	H7002_002_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					653.00	33																														33							33					33				33			33			
H7002	002	0	1	04	01	H7002_002_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H7002	002	0	1	04	01	H7002_002_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H7002	002	0	1	04	01	H7002_002_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H7002	002	0	1	04	01	H7002_002_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00				
H7006	001	0	1	04	01	H7006_001_0	11	4	Specialty Tier	1	4	100100	1	1	110100000010101000000111	31		90							1	31		90							31		31	14	31	14					200.00	33		33																					33		33																	33				33			33			
H7006	001	0	1	04	01	H7006_001_0	11	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		75.00		150.00																						75.00		150.00																		75.00								75.00				
H7006	001	0	1	04	01	H7006_001_0	11	2	Preferred Brand	1	4	000101	1	2	110100000010101000000111	31		90							1	31		90							31		31	14	31	14		35.00		70.00																						35.00		70.00																		35.00					35.00			35.00				
H7006	001	0	1	04	01	H7006_001_0	11	1	Generic	1	4	010010	1	2	110100000010101000000111	31		90							1	31		90							31		31	14	31	14		4.00		8.00																						4.00		8.00																		4.00					4.00			4.00				
H7006	003	0	1	04	01	H7006_003_0	9	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		85.00		170.00																						85.00		170.00																		85.00								85.00				
H7006	003	0	1	04	01	H7006_003_0	9	4	Specialty Tier	1	4	100100	1	1	110100000010101000000111	31		90							1	31		90							31		31	14	31	14					200.00	33		33																					33		33																	33				33			33			
H7006	003	0	1	04	01	H7006_003_0	9	1	Generic	1	4	010001	1	2	110100000010101000000111	31		90							1	31		90							31		31	14	31	14		6.00		12.00																						6.00		12.00																		6.00					6.00			6.00				
H7006	003	0	1	04	01	H7006_003_0	9	2	Preferred Brand	1	4	000101	1	2	110100000010101000000111	31		90							1	31		90							31		31	14	31	14		40.00		80.00																						40.00		80.00																		40.00					40.00			40.00				
H7086	001	0	1	01	01	H7086_001_0	7	1	Generic	1	4	010000	1	2	010100000010001000000100	31		93							1			93							31		31					0.00		0.00																								0.00																		0.00					0.00							
H7086	001	0	1	01	01	H7086_001_0	7	2	Brand	1	4	000010	1	2	110100000010001000000001	31		93							1			93							31				31	14		60.00		180.00																								180.00																		60.00								60.00				
H7149	001	0	1	01	01	H7149_001_0	8	3	Preferred Brand	1	4	000001	1	2	100010110110101000000001				30		90	30		90	2	30		90							30				31	14										45.00		135.00						45.00		135.00						45.00		135.00																		45.00								45.00				
H7149	001	0	1	01	01	H7149_001_0	8	5	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													901.34	33							901.34	33																										33				33			33			
H7149	001	0	1	01	01	H7149_001_0	8	4	Non-Preferred Brand	1	4	100100	1	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										95.00		285.00						95.00		285.00						95.00		285.00																		95.00					95.00			95.00				
H7149	001	0	1	01	01	H7149_001_0	8	2	Non-Preferred Generic	1	4	000100	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													9.00		27.00						9.00		27.00						9.00		27.00																		9.00					9.00							
H7149	001	0	1	01	01	H7149_001_0	8	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													4.00		12.00						9.00		27.00						4.00		12.00																		9.00					9.00							
H7149	004	0	1	01	01	H7149_004_0	5	4	Non-Preferred Brand	1	4	100100	1	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										80.00		240.00						80.00		240.00						80.00		240.00																		80.00					80.00			80.00				
H7149	004	0	1	01	01	H7149_004_0	5	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													3.00		9.00						7.00		21.00						3.00		9.00																		7.00					7.00							
H7149	004	0	1	01	01	H7149_004_0	5	3	Preferred Brand	1	4	000001	1	2	100010110110101000000001				30		90	30		90	2	30		90							30				31	14										40.00		120.00						40.00		120.00						40.00		120.00																		40.00								40.00				
H7149	004	0	1	01	01	H7149_004_0	5	2	Non-Preferred Generic	1	4	000100	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													7.00		21.00						7.00		21.00						7.00		21.00																		7.00					7.00							
H7149	004	0	1	01	01	H7149_004_0	5	5	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													1133.49	33							1133.49	33																										33				33			33			
H7173	001	0	1	01	01	H7173_001_0	9	4	Injectable Drugs	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	7		95.00		95.00																								95.00																		95.00								95.00				
H7173	001	0	1	01	01	H7173_001_0	9	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							2			90							30				31	7		95.00		95.00																								95.00																		95.00								95.00				
H7173	001	0	1	01	01	H7173_001_0	9	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	7		45.00		45.00																								45.00																		45.00								45.00				
H7173	001	0	1	01	01	H7173_001_0	9	1	Generic	1	4	010000	1	2	010100000010001000000100	30		90							2			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H7187	003	0	1	01	01	H7187_003_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					537.00	33		33																														33							33			33				33			33			
H7187	003	0	1	01	01	H7187_003_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H7187	003	0	1	01	01	H7187_003_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H7187	003	0	1	01	01	H7187_003_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															0.00							18.00				6.00					6.00							
H7187	003	0	1	01	01	H7187_003_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															0.00							9.00				3.00					3.00							
H7187	009	0	1	01	01	H7187_009_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															0.00							9.00				3.00					3.00							
H7187	009	0	1	01	01	H7187_009_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															0.00							18.00				6.00					6.00							
H7187	009	0	1	01	01	H7187_009_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					441.00	33		33																														33							33			33				33			33			
H7187	009	0	1	01	01	H7187_009_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H7187	009	0	1	01	01	H7187_009_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H7188	003	0	1	04	01	H7188_003_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		11.00		33.00																													0.00		0.00					11.00		33.00				11.00					11.00			11.00				
H7188	003	0	1	04	01	H7188_003_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		43.00		129.00																													43.00		119.00					43.00		129.00				43.00					43.00			43.00				
H7188	003	0	1	04	01	H7188_003_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00				
H7188	003	0	1	04	01	H7188_003_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					881.00	33																														33							33					33				33			33			
H7188	003	0	1	04	01	H7188_003_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H7188	003	0	1	04	01	H7188_003_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		43.00		129.00																													43.00		119.00					43.00		129.00				43.00					43.00			43.00		2	2	
H7188	003	0	1	04	01	H7188_003_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		11.00		33.00																													0.00		0.00					11.00		33.00				11.00					11.00			11.00		2	2	
H7188	003	0	1	04	01	H7188_003_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00		2	3	
H7188	003	0	1	04	01	H7188_003_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					958.00	33																														33							33					33				33			33	2	3	
H7188	003	0	1	04	01	H7188_003_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H7188	006	0	1	04	01	H7188_006_0	6	3	Preferred Brand	3	4	000101	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													23.00	19		19					32.00	25		25												19		19					25		25			25				25			25	2	2	
H7188	006	0	1	04	01	H7188_006_0	6	4	Non-Preferred Brand	3	4	110000	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													121.00	30		30					123.00	48		48												30		30					48		48			48				48			48	2	3	
H7188	006	0	1	04	01	H7188_006_0	6	5	Specialty Tier	3	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													735.00	25							746.00	25														25							25					25				25			25	2	3	
H7188	006	0	1	04	01	H7188_006_0	6	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										1.00		3.00						8.00		24.00													0.00		0.00					8.00		24.00				8.00					8.00			8.00				
H7188	006	0	1	04	01	H7188_006_0	6	2	Non-Preferred Generic	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										3.00		9.00						10.00		30.00													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H7188	006	0	1	04	01	H7188_006_0	6	5	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													652.00	25							662.00	25														25							25					25				25			25			
H7188	006	0	1	04	01	H7188_006_0	6	4	Non-Preferred Brand	1	4	110000	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													92.00	30		30					94.00	48		48												30		30					48		48			48				48			48			
H7188	006	0	1	04	01	H7188_006_0	6	3	Preferred Brand	1	4	000101	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													17.00	19		19					24.00	25		25												19		19					25		25			25				25			25			
H7188	006	0	1	04	01	H7188_006_0	6	2	Non-Preferred Generic	3	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										3.00		9.00						10.00		30.00													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	3	
H7200	006	0	1	01	01	H7200_006_0	5	3	Preferred Brand	1	4	000001	1	1	111100000010111000000001	31	62	93							2	31	62	93							31				31	1					58.00	25	25	25																					25	25	25																	25							25			
H7200	006	0	1	01	01	H7200_006_0	5	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	31	62	93							2	31	62	93							31		31	1				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	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	31	62	93							2	31	62	93							31		31	1				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	4	Non-Preferred Brand	1	4	100000	1	1	111100000010111000000001	31	62	93							2	31	62	93							31				31	1					67.00	25	25	25																					25	25	25																	25							25			
H7200	006	0	1	01	01	H7200_006_0	5	5	Specialty Tier	1	4	100100	1	1	111100000010111000000111	31	62	93							2	31	62	93							31		31	1	31	1					386.00	25	25	25																					25	25	25																	25				25			25			
H7200	006	0	1	01	01	H7200_006_0	5	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	31	62	93							2	31	62	93							31		31	1				0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00					1		
H7200	006	0	1	01	01	H7200_006_0	5	2	Non-Preferred Generic	3	4	000100	1	2	011100000010111000000110	31	62	93							2	31	62	93							31		31	1				0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00					1		
H7200	007	0	1	01	01	H7200_007_0	7	3	Preferred Brand	1	4	000001	1	1	111100000010111000000001	31	62	93							2	31	62	93							31				31	1					47.00	25	25	25																					25	25	25																	25							25			
H7200	007	0	1	01	01	H7200_007_0	7	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	31	62	93							2	31	62	93							31		31	1				4.00	8.00	12.00																						4.00	6.00	8.00																		4.00					4.00							
H7200	007	0	1	01	01	H7200_007_0	7	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	31	62	93							2	31	62	93							31		31	1				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	7	4	Non-Preferred Brand	1	4	100000	1	1	111100000010111000000001	31	62	93							2	31	62	93							31				31	1					58.00	25	25	25																					25	25	25																	25							25			
H7200	007	0	1	01	01	H7200_007_0	7	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	31	62	93							2	31	62	93							31		31	1				0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00					1		
H7200	007	0	1	01	01	H7200_007_0	7	5	Specialty Tier	1	4	100100	1	1	111100000010111000000111	31	62	93							2	31	62	93							31		31	1	31	1					385.00	25	25	25																					25	25	25																	25				25			25			
H7220	003	0	1	01	01	H7220_003_0	6	4	Specialty Tier	1	4	100000	1	1	110000000001100000000001	31										31										14			31	14					1783.00	33																							33																				33						33			
H7220	003	0	1	01	01	H7220_003_0	6	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		90							2	31		90							31				31	14		85.00		255.00																						85.00		255.00																		85.00								85.00				
H7220	003	0	1	01	01	H7220_003_0	6	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		90							2	31		90							31				31	14		40.00		120.00																						40.00		120.00																		40.00								40.00				
H7220	003	0	1	01	01	H7220_003_0	6	1	Generic	1	4	010000	1	2	010100000010101000000110	31		90							2	31		90							31		31	14				7.00		21.00																						7.00		21.00																		7.00					7.00							
H7220	004	0	1	02	01	H7220_004_0	6	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		90							2	31		90							31				31	14		85.00		234.00																						85.00		234.00																		85.00								85.00				
H7220	004	0	1	02	01	H7220_004_0	6	4	Specialty Tier	1	4	100000	1	1	110000000001100000000001	31										31										14			31	14					1417.00	33																							33																				33						33			
H7220	004	0	1	02	01	H7220_004_0	6	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		90							2	31		90							31				31	14		40.00		110.00																						40.00		110.00																		40.00								40.00				
H7220	004	0	1	02	01	H7220_004_0	6	1	Generic	3	4	010000	1	2	010100000010101000000110	31		90							2	31		90							31		31	14				10.00		30.00																						10.00		30.00																		10.00					10.00					1		
H7220	004	0	1	02	01	H7220_004_0	6	1	Generic	1	4	010000	1	2	010100000010101000000110	31		90							2	31		90							31		31	14				7.00		19.00																						7.00		19.00																		7.00					7.00							
H7281	001	0	1	01	01	H7281_001_0	9	1	Preferred Generic	1	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					5.00	10.00	15.00																								6.00																		5.00					5.00							
H7281	001	0	1	01	01	H7281_001_0	9	2	Non-Preferred Generic	1	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		10.00	20.00	30.00																								21.00																		10.00					10.00			10.00				
H7281	001	0	1	01	01	H7281_001_0	9	3	Preferred Brand	1	4	000001	1	2	111100000010001000000001	30	60	90							2			90							30				31	14		40.00	80.00	120.00																								110.00																		40.00								40.00				
H7281	001	0	1	01	01	H7281_001_0	9	4	Non-Preferred Brand	1	4	100100	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		80.00	160.00	240.00																								230.00																		80.00					80.00			80.00				
H7281	001	0	1	01	01	H7281_001_0	9	5	Specialty Tier	1	4	010010	1	1	111100000010001000000101	30	60	90							2			90							30		31		31	14					351.59	26	26	26																							26																	26				26			26			
H7281	002	0	1	01	01	H7281_002_0	7	5	Specialty Tier	1	4	010010	1	1	111100000010001000000101	30	60	90							2			90							30		31		31	14					233.45	33	33	33																							33																	33				33			33			
H7281	002	0	1	01	01	H7281_002_0	7	4	Non-Preferred Brand	1	4	100100	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		80.00	160.00	240.00																								230.00																		80.00					80.00			80.00				
H7281	002	0	1	01	01	H7281_002_0	7	3	Preferred Brand	1	4	000001	1	2	111100000010001000000001	30	60	90							2			90							30				31	14		40.00	80.00	120.00																								110.00																		40.00								40.00				
H7281	002	0	1	01	01	H7281_002_0	7	2	Non-Preferred Generic	1	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		8.00	16.00	24.00																								15.00																		8.00					8.00			8.00				
H7281	002	0	1	01	01	H7281_002_0	7	1	Preferred Generic	1	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					3.00	6.00	9.00																								0.00																		3.00					3.00							
H7281	005	0	1	01	01	H7281_005_0	9	5	Specialty Tier	1	4	010010	1	1	111100000010001000000101	30	60	90							2			90							30		31		31	14					308.06	26	26	26																							26																	26				26			26			
H7281	005	0	1	01	01	H7281_005_0	9	6	Select Diabetic Drugs	1	4	010010	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		5.00	10.00	15.00																								5.00																		5.00					5.00			5.00				
H7281	005	0	1	01	01	H7281_005_0	9	1	Preferred Generic	1	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					5.00	10.00	15.00																								6.00																		5.00					5.00							
H7281	005	0	1	01	01	H7281_005_0	9	4	Non-Preferred Brand	1	4	100100	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		80.00	160.00	240.00																								230.00																		80.00					80.00			80.00				
H7281	005	0	1	01	01	H7281_005_0	9	3	Preferred Brand	1	4	000001	1	2	111100000010001000000001	30	60	90							2			90							30				31	14		40.00	80.00	120.00																								110.00																		40.00								40.00				
H7281	005	0	1	01	01	H7281_005_0	9	2	Non-Preferred Generic	1	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		10.00	20.00	30.00																								21.00																		10.00					10.00			10.00				
H7292	001	0	1	01	01	H7292_001_0	3	2	Brand	1	4	000010	1	2	110100000010001000000001	30		90							1			90							30				31	14		48.00		144.00																								144.00																		48.00								48.00				
H7292	001	0	1	01	01	H7292_001_0	3	1	Generic	1	4	010000	1	2	010100000010001000000100	30		90							1			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H7301	002	0	1	04	01	H7301_002_0	7	3	Non-Preferred Brand	1	4	100100	1	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										80.00		240.00						95.00		285.00						80.00		240.00																		95.00					95.00			95.00				
H7301	002	0	1	04	01	H7301_002_0	7	2	Preferred Brand	1	4	000001	1	2	100010110110101000000001				30		90	30		90	2	30		90							30				31	14										40.00		120.00						45.00		135.00						40.00		120.00																		45.00								45.00				
H7301	002	0	1	04	01	H7301_002_0	7	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													5.00		15.00						8.00		24.00						5.00		15.00																		8.00					8.00							
H7301	002	0	1	04	01	H7301_002_0	7	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													867.49	33							867.49	33																										33				33			33			
H7306	001	0	1	04	01	H7306_001_0	13	3	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		70.00		210.00																						70.00		210.00																		70.00					70.00			70.00				
H7306	001	0	1	04	01	H7306_001_0	13	4	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					716.94	33																																										33				33			33			
H7306	001	0	1	04	01	H7306_001_0	13	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					3.00		9.00																						3.00		9.00																		3.00					3.00							
H7306	001	0	1	04	01	H7306_001_0	13	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		35.00		105.00																						35.00		105.00																		35.00								35.00				
H7306	003	0	1	04	01	H7306_003_0	9	3	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		70.00		210.00																						70.00		210.00																		70.00					70.00			70.00				
H7306	003	0	1	04	01	H7306_003_0	9	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		35.00		105.00																						35.00		105.00																		35.00								35.00				
H7306	003	0	1	04	01	H7306_003_0	9	4	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					639.60	33																																										33				33			33			
H7306	003	0	1	04	01	H7306_003_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					3.00		9.00																						3.00		9.00																		3.00					3.00							
H7419	001	0	1	48	05	H7419_001_0	8	2	Brand	1	4	000010	3	2	110100000010001000000001	30		90							2			90							30				31	14	0.00	0.00		0.00																								0.00																		0.00							0.00	0.00				
H7419	001	0	1	48	05	H7419_001_0	8	1	Generic	1	4	010000	3	2	010100000010001000000100	30		90							2			90							30		31				0.00	0.00		0.00																								0.00																		0.00				0.00	0.00							
H7526	001	0	1	01	01	H7526_001_0	4	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	31		90							1			90							31				31	14		67.00		201.00																								134.00																		67.00								67.00				
H7526	001	0	1	01	01	H7526_001_0	4	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	31		90							1			90							31				31	14		34.00		102.00																								68.00																		34.00								34.00				
H7526	001	0	1	01	01	H7526_001_0	4	1	Generic	1	4	010000	1	2	010100000010001000000100	31		90							1			90							31		31					10.00		30.00																								20.00																		10.00					10.00							
H7526	001	0	1	01	01	H7526_001_0	4	4	Specialty Tier	1	4	010010	1	1	110100000010001000000101	31		90							1			90							31		31		31	14					287.22	25		25																							25																	25				25			25			
H7526	003	0	1	01	01	H7526_003_0	4	4	Specialty Tier	1	4	010010	1	1	110100000010001000000101	31		90							1			90							31		31		31	14					289.77	25		25																							25																	25				25			25			
H7526	003	0	1	01	01	H7526_003_0	4	1	Generic	1	4	010000	1	2	010100000010001000000100	31		90							1			90							31		31					10.00		30.00																								20.00																		10.00					10.00							
H7526	003	0	1	01	01	H7526_003_0	4	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	31		90							1			90							31				31	14		34.00		102.00																								68.00																		34.00								34.00				
H7526	003	0	1	01	01	H7526_003_0	4	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	31		90							1			90							31				31	14		67.00		201.00																								134.00																		67.00								67.00				
H7526	004	0	1	01	01	H7526_004_0	4	4	Specialty Tier	1	4	010010	1	1	110100000010001000000101	31		90							1			90							31		31		31	14					350.49	25		25																							25																	25				25			25			
H7526	004	0	1	01	01	H7526_004_0	4	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	31		90							1			90							31				31	14		67.00		201.00																								134.00																		67.00								67.00				
H7526	004	0	1	01	01	H7526_004_0	4	1	Generic	1	4	010000	1	2	010100000010001000000100	31		90							1			90							31		31					10.00		30.00																								20.00																		10.00					10.00							
H7526	004	0	1	01	01	H7526_004_0	4	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	31		90							1			90							31				31	14		34.00		102.00																								68.00																		34.00								34.00				
H7678	001	0	1	01	01	H7678_001_0	7	1	Generic	1	4	010000	1	2	011100000010111000000110	31	60	90							1	31	60	90							31		31	14				0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00							
H7678	001	0	1	01	01	H7678_001_0	7	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	31	60	90							1	31	60	90							31				31	14		45.00	90.00	135.00																						45.00	90.00	135.00																		45.00								45.00				
H7678	001	0	1	01	01	H7678_001_0	7	1	Generic	3	4	010000	1	2	011100000010111000000110	31	60	90							1	31	60	90							31		31	14				0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00					1		
H7678	001	0	1	01	01	H7678_001_0	7	4	Specialty Tier	1	4	010010	1	1	110000000010100000000111	31										31									31		31	14	31	14					475.60	25																							25																			25				25			25			
H7678	001	0	1	01	01	H7678_001_0	7	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	31	60	90							1	31	60	90							31				31	14		95.00	190.00	285.00																						95.00	190.00	285.00																		95.00								95.00				
H7728	001	0	1	04	01	H7728_001_0	13	1	Preferred Generic	1	3	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				5.00	10.00	15.00																						5.00	10.00	7.50																		5.00					5.00							
H7728	001	0	1	04	01	H7728_001_0	13	2	Non-Preferred Generic	1	3	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				10.00	20.00	30.00																						10.00	20.00	15.00																		10.00					10.00							
H7728	001	0	1	04	01	H7728_001_0	13	3	Preferred Brand	1	3	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		39.00	78.00	117.00																						39.00	78.00	97.50																		39.00					39.00			39.00				
H7728	001	0	1	04	01	H7728_001_0	13	4	Non-Preferred Brand	1	3	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		80.00	160.00	240.00																						80.00	160.00	200.00																		80.00					80.00			80.00				
H7728	001	0	1	04	01	H7728_001_0	13	5	Injectable Drugs	1	3	010010		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H7728	001	0	1	04	01	H7728_001_0	13	6	Specialty Tier	1	3	010010		1	110000000010100000000111	30										30									30		34	14	34	14					860.00	33																							33																			33				33			33			
H7787	001	0	1	04	01	H7787_001_0	6	1	Preferred Generic	1	4	001000	1	2	011100000010001000000100	30	60	90							2			90							30		31					0.00	0.00	0.00																								0.00																		0.00					0.00							
H7787	001	0	1	04	01	H7787_001_0	6	2	Non-Preferred Generic	1	4	000101	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		4.00	8.00	12.00																								3.00																		4.00					4.00			4.00				
H7787	001	0	1	04	01	H7787_001_0	6	3	Preferred Brand	1	4	000001	1	2	111100000010001000000001	30	60	90							2			90							30				31	14		30.00	60.00	90.00																								80.00																		30.00								30.00				
H7787	001	0	1	04	01	H7787_001_0	6	4	Non-Preferred Brand	1	4	100100	1	2	111100000010001000000101	30	60	90							2			90							30		31		31	14		60.00	120.00	180.00																								170.00																		60.00					60.00			60.00				
H7787	001	0	1	04	01	H7787_001_0	6	5	Specialty Tier	1	4	010010	1	1	111100000010001000000101	30	60	90							2			90							30		31		31	14					305.73	33	33	33																							33																	33				33			33			
H7811	001	0	1	01	01	H7811_001_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		2.00		6.00																						2.00		4.00																		2.00					2.00			2.00				
H7811	001	0	1	01	01	H7811_001_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		11.00		33.00																						11.00		22.00																		11.00					11.00			11.00				
H7811	001	0	1	01	01	H7811_001_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		45.00		135.00																						45.00		112.50																		45.00					45.00			45.00				
H7811	001	0	1	01	01	H7811_001_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		95.00		285.00																						95.00		237.50																		95.00					95.00			95.00				
H7811	001	0	1	01	01	H7811_001_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					860.00	33																							33																			33				33			33			
H7811	002	0	1	01	01	H7811_002_0	8	1	Preferred Generic	1	4	001010	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		2.00		6.00																						2.00		4.00																		2.00					2.00			2.00				
H7811	002	0	1	01	01	H7811_002_0	8	2	Non-Preferred Generic	1	4	000101	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		11.00		33.00																						11.00		22.00																		11.00					11.00			11.00				
H7811	002	0	1	01	01	H7811_002_0	8	3	Preferred Brand	1	4	000101	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		45.00		135.00																						45.00		112.50																		45.00					45.00			45.00				
H7811	002	0	1	01	01	H7811_002_0	8	4	Non-Preferred Brand	1	4	110000	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		95.00		285.00																						95.00		237.50																		95.00					95.00			95.00				
H7811	002	0	1	01	01	H7811_002_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					907.00	33																							33																			33				33			33			
H7908	001	0	1	01	01	H7908_001_0	7	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					530.11	33	33	33																												33	33	33					33	33	33				33			33			33			
H7908	001	0	1	01	01	H7908_001_0	7	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					7.00	14.00	21.00																													7.00	14.00	14.00					7.00	14.00	21.00					7.00				7.00							
H7908	001	0	1	01	01	H7908_001_0	7	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H7908	001	0	1	01	01	H7908_001_0	7	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H7908	001	0	1	01	01	H7908_001_0	7	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H7917	008	0	1	04	01	H7917_008_0	10	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							1	30		90							30				31	14		30.00		90.00																						30.00		75.00																		30.00								30.00				
H7917	008	0	1	04	01	H7917_008_0	10	1	Generic	1	4	010000	1	2	010100000010101000000110	30		90							1	30		90							30		31	14				4.00		12.00																						4.00		10.00																		4.00					4.00							
H7917	008	0	1	04	01	H7917_008_0	10	4	Specialty Tier	1	4	000001	1	1	110100000010101000000001	30		90							1	30		90							30				31	14					835.62	33		33																					33		33																	33							33			
H7917	008	0	1	04	01	H7917_008_0	10	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							1	30		90							30				31	14		50.00		150.00																						50.00		125.00																		50.00								50.00				
H7917	009	0	1	04	01	H7917_009_0	10	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							1	30		90							30				31	14		30.00		90.00																						30.00		75.00																		30.00								30.00				
H7917	009	0	1	04	01	H7917_009_0	10	1	Generic	1	4	010000	1	2	010100000010101000000110	30		90							1	30		90							30		31	14				4.00		12.00																						4.00		10.00																		4.00					4.00							
H7917	009	0	1	04	01	H7917_009_0	10	4	Specialty Tier	1	4	000001	1	1	110100000010101000000001	30		90							1	30		90							30				31	14					795.98	33		33																					33		33																	33							33			
H7917	009	0	1	04	01	H7917_009_0	10	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							1	30		90							30				31	14		50.00		150.00																						50.00		125.00																		50.00								50.00				
H7917	010	0	1	04	01	H7917_010_0	10	4	Specialty Tier	1	4	000001	1	1	110100000010101000000001	30		90							1	30		90							30				31	14					937.90	33		33																					33		33																	33							33			
H7917	010	0	1	04	01	H7917_010_0	10	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							1	30		90							30				31	14		50.00		150.00																						50.00		125.00																		50.00								50.00				
H7917	010	0	1	04	01	H7917_010_0	10	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							1	30		90							30				31	14		30.00		90.00																						30.00		75.00																		30.00								30.00				
H7917	010	0	1	04	01	H7917_010_0	10	1	Generic	1	4	010000	1	2	010100000010101000000110	30		90							1	30		90							30		31	14				4.00		12.00																						4.00		10.00																		4.00					4.00							
H7917	011	0	1	04	01	H7917_011_0	10	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							1	30		90							30				31	14		50.00		150.00																						50.00		125.00																		50.00								50.00				
H7917	011	0	1	04	01	H7917_011_0	10	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							1	30		90							30				31	14		30.00		90.00																						30.00		75.00																		30.00								30.00				
H7917	011	0	1	04	01	H7917_011_0	10	1	Generic	1	4	010000	1	2	010100000010101000000110	30		90							1	30		90							30		31	14				4.00		12.00																						4.00		10.00																		4.00					4.00							
H7917	011	0	1	04	01	H7917_011_0	10	4	Specialty Tier	1	4	000001	1	1	110100000010101000000001	30		90							1	30		90							30				31	14					796.27	33		33																					33		33																	33							33			
H7917	012	0	1	04	01	H7917_012_0	10	4	Specialty Tier	1	4	000001	1	1	110100000010101000000001	30		90							1	30		90							30				31	14					813.07	33		33																					33		33																	33							33			
H7917	012	0	1	04	01	H7917_012_0	10	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							1	30		90							30				31	14		65.00		195.00																						65.00		162.50																		65.00								65.00				
H7917	012	0	1	04	01	H7917_012_0	10	1	Generic	1	4	010000	1	2	010100000010101000000110	30		90							1	30		90							30		31	14				4.00		12.00																						4.00		10.00																		4.00					4.00							
H7917	012	0	1	04	01	H7917_012_0	10	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							1	30		90							30				31	14		30.00		90.00																						30.00		75.00																		30.00								30.00				
H7917	013	0	1	04	01	H7917_013_0	10	1	Generic	1	4	010000	1	2	010100000010101000000110	30		90							1	30		90							30		31	14				4.00		12.00																						4.00		10.00																		4.00					4.00							
H7917	013	0	1	04	01	H7917_013_0	10	4	Specialty Tier	1	4	000001	1	1	110100000010101000000001	30		90							1	30		90							30				31	14					759.90	33		33																					33		33																	33							33			
H7917	013	0	1	04	01	H7917_013_0	10	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							1	30		90							30				31	14		65.00		195.00																						65.00		162.50																		65.00								65.00				
H7917	013	0	1	04	01	H7917_013_0	10	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							1	30		90							30				31	14		30.00		90.00																						30.00		75.00																		30.00								30.00				
H7917	014	0	1	04	01	H7917_014_0	10	4	Specialty Tier	1	4	000001	1	1	110100000010101000000001	30		90							1	30		90							30				31	14					717.24	33		33																					33		33																	33							33			
H7917	014	0	1	04	01	H7917_014_0	10	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							1	30		90							30				31	14		65.00		195.00																						65.00		162.50																		65.00								65.00				
H7917	014	0	1	04	01	H7917_014_0	10	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							1	30		90							30				31	14		30.00		90.00																						30.00		75.00																		30.00								30.00				
H7917	014	0	1	04	01	H7917_014_0	10	1	Generic	1	4	010000	1	2	010100000010101000000110	30		90							1	30		90							30		31	14				4.00		12.00																						4.00		10.00																		4.00					4.00							
H7917	015	0	1	04	01	H7917_015_0	10	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							1	30		90							30				31	14		65.00		195.00																						65.00		162.50																		65.00								65.00				
H7917	015	0	1	04	01	H7917_015_0	10	1	Generic	1	4	010000	1	2	010100000010101000000110	30		90							1	30		90							30		31	14				4.00		12.00																						4.00		10.00																		4.00					4.00							
H7917	015	0	1	04	01	H7917_015_0	10	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							1	30		90							30				31	14		30.00		90.00																						30.00		75.00																		30.00								30.00				
H7917	015	0	1	04	01	H7917_015_0	10	4	Specialty Tier	1	4	000001	1	1	110100000010101000000001	30		90							1	30		90							30				31	14					397.83	33		33																					33		33																	33							33			
H7917	030	0	1	04	01	H7917_030_0	9	5	Specialty Tier	1	4	100000	1	1	110100000010101000000001	30		90							1	30		90							30				31	14					82.41	33		33																					33		33																	33							33			
H7917	030	0	1	04	01	H7917_030_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							1	30		90							30				31	14		80.00		240.00																						80.00		200.00																		80.00								80.00				
H7917	030	0	1	04	01	H7917_030_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							1	30		90							30				31	14		45.00		135.00																						45.00		112.50																		45.00								45.00				
H7917	030	0	1	04	01	H7917_030_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010101000000110	30		90							1	30		90							30		31	14				4.00		12.00																						4.00		10.00																		4.00					4.00							
H7917	030	0	1	04	01	H7917_030_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000110	30		90							1	30		90							30		31	14				12.00		36.00																						12.00		30.00																		12.00					12.00							
H7917	031	0	1	04	01	H7917_031_0	9	5	Specialty Tier	1	4	100000	1	1	110100000010101000000001	30		90							1	30		90							30				31	14					82.41	33		33																					33		33																	33							33			
H7917	031	0	1	04	01	H7917_031_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							1	30		90							30				31	14		45.00		135.00																						45.00		112.50																		45.00								45.00				
H7917	031	0	1	04	01	H7917_031_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							1	30		90							30				31	14		80.00		240.00																						80.00		200.00																		80.00								80.00				
H7917	031	0	1	04	01	H7917_031_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000110	30		90							1	30		90							30		31	14				12.00		36.00																						12.00		30.00																		12.00					12.00							
H7917	031	0	1	04	01	H7917_031_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010101000000110	30		90							1	30		90							30		31	14				4.00		12.00																						4.00		10.00																		4.00					4.00							
H7917	032	0	1	04	01	H7917_032_0	9	5	Specialty Tier	1	4	100000	1	1	110100000010101000000001	30		90							1	30		90							30				31	14					82.41	33		33																					33		33																	33							33			
H7917	032	0	1	04	01	H7917_032_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							1	30		90							30				31	14		80.00		240.00																						80.00		200.00																		80.00								80.00				
H7917	032	0	1	04	01	H7917_032_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							1	30		90							30				31	14		45.00		135.00																						45.00		112.50																		45.00								45.00				
H7917	032	0	1	04	01	H7917_032_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000110	30		90							1	30		90							30		31	14				12.00		36.00																						12.00		30.00																		12.00					12.00							
H7917	032	0	1	04	01	H7917_032_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010101000000110	30		90							1	30		90							30		31	14				4.00		12.00																						4.00		10.00																		4.00					4.00							
H7917	033	0	1	04	01	H7917_033_0	7	5	Specialty Tier	1	4	100000	1	1	110100000010101000000001	30		90							1	30		90							30				31	14					82.41	33		33																					33		33																	33							33			
H7917	033	0	1	04	01	H7917_033_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							1	30		90							30				31	14		80.00		240.00																						80.00		200.00																		80.00								80.00				
H7917	033	0	1	04	01	H7917_033_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							1	30		90							30				31	14		45.00		135.00																						45.00		112.50																		45.00								45.00				
H7917	033	0	1	04	01	H7917_033_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000110	30		90							1	30		90							30		31	14				12.00		36.00																						12.00		30.00																		12.00					12.00							
H7917	033	0	1	04	01	H7917_033_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010101000000110	30		90							1	30		90							30		31	14				4.00		12.00																						4.00		10.00																		4.00					4.00							
H7949	001	0	1	01	01	H7949_001_0	7	2	Non-Preferred Generic	1	4	000110	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		5.00		15.00																															5.00							15.00				5.00					5.00			5.00				
H7949	001	0	1	01	01	H7949_001_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00							
H7949	001	0	1	01	01	H7949_001_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		38.00		114.00																															104.00							114.00				38.00					38.00			38.00				
H7949	001	0	1	01	01	H7949_001_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		92.00		276.00																															266.00							276.00				92.00					92.00			92.00				
H7949	001	0	1	01	01	H7949_001_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					773.00	33		33																														33							33			33				33			33			
H7949	001	0	1	01	01	H7949_001_0	7	1	Preferred Generic	3	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00					1		
H7949	001	0	1	01	01	H7949_001_0	7	2	Non-Preferred Generic	3	4	000110	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		5.00		15.00																															5.00							15.00				5.00					5.00			5.00		1		
H8050	001	0	1	01	01	H8050_001_0	7	1	Generic	1	4	010000	1	2	010100000001101000000100	30		90							2	30		90								14	34					5.00		15.00																						5.00		15.00																			5.00				5.00							
H8050	001	0	1	01	01	H8050_001_0	7	4	Specialty Tier	1	4	010010	1	1	110100000001101000000111	30		90							2	30		90								14	34	14	34	14					461.00	33		33																					33		33																		33			33			33			
H8050	001	0	1	01	01	H8050_001_0	7	3	Non-Preferred Brand	1	4	100100	1	2	110100000001101000000111	30		90							2	30		90								14	34	14	34	14		95.00		285.00																						95.00		285.00																			95.00				95.00			95.00				
H8050	001	0	1	01	01	H8050_001_0	7	2	Preferred Brand	1	4	010001	1	2	110100000001101000000111	30		90							2	30		90								14	34	14	34	14		35.00		105.00																						35.00		105.00																			35.00				35.00			35.00				
H8050	005	0	1	01	01	H8050_005_0	7	1	Generic	1	4	010000	1	2	010100000001101000000100	30		90							2	30		90								14	34					6.00		18.00																						6.00		18.00																			6.00				6.00							
H8050	005	0	1	01	01	H8050_005_0	7	3	Non-Preferred Brand	1	4	100100	1	2	110100000001101000000111	30		90							2	30		90								14	34	14	34	14		95.00		285.00																						95.00		285.00																			95.00				95.00			95.00				
H8050	005	0	1	01	01	H8050_005_0	7	2	Preferred Brand	1	4	010001	1	2	110100000001101000000111	30		90							2	30		90								14	34	14	34	14		45.00		135.00																						45.00		135.00																			45.00				45.00			45.00				
H8050	005	0	1	01	01	H8050_005_0	7	4	Specialty Tier	1	4	010010	1	1	110100000001101000000111	30		90							2	30		90								14	34	14	34	14					471.00	33		33																					33		33																		33			33			33			
H8050	006	0	1	01	01	H8050_006_0	7	1	Generic	1	4	010000	1	2	010100000001101000000100	30		90							2	30		90								14	34					5.00		15.00																						5.00		15.00																			5.00				5.00							
H8050	006	0	1	01	01	H8050_006_0	7	2	Preferred Brand	1	4	010001	1	2	110100000001101000000111	30		90							2	30		90								14	34	14	34	14		35.00		105.00																						35.00		105.00																			35.00				35.00			35.00				
H8050	006	0	1	01	01	H8050_006_0	7	4	Specialty Tier	1	4	010010	1	1	110100000001101000000111	30		90							2	30		90								14	34	14	34	14					563.00	33		33																					33		33																		33			33			33			
H8050	006	0	1	01	01	H8050_006_0	7	3	Non-Preferred Brand	1	4	100100	1	2	110100000001101000000111	30		90							2	30		90								14	34	14	34	14		95.00		285.00																						95.00		285.00																			95.00				95.00			95.00				
H8050	007	0	1	01	01	H8050_007_0	6	1	Generic	1	4	010000	1	2	010100000001101000000100	30		90							2	30		90								14	34					5.00		15.00																						5.00		15.00																			5.00				5.00							
H8050	007	0	1	01	01	H8050_007_0	6	4	Specialty Tier	1	4	010010	1	1	110100000001101000000111	30		90							2	30		90								14	34	14	34	14					556.00	33		33																					33		33																		33			33			33			
H8050	007	0	1	01	01	H8050_007_0	6	2	Preferred Brand	1	4	010001	1	2	110100000001101000000111	30		90							2	30		90								14	34	14	34	14		35.00		105.00																						35.00		105.00																			35.00				35.00			35.00				
H8050	007	0	1	01	01	H8050_007_0	6	3	Non-Preferred Brand	1	4	100100	1	2	110100000001101000000111	30		90							2	30		90								14	34	14	34	14		95.00		285.00																						95.00		285.00																			95.00				95.00			95.00				
H8064	002	0	1	04	01	H8064_002_0	12	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		31	14				7.00	14.00	21.00																						7.00	14.00	21.00																		7.00					7.00					1		
H8064	002	0	1	04	01	H8064_002_0	12	5	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					33.00	33	33	33																					33	33	33																	33				33			33			
H8064	002	0	1	04	01	H8064_002_0	12	4	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		80.00	160.00	240.00																						80.00	160.00	200.00																		80.00								80.00				
H8064	002	0	1	04	01	H8064_002_0	12	3	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		40.00	80.00	120.00																						40.00	80.00	100.00																		40.00								40.00				
H8064	002	0	1	04	01	H8064_002_0	12	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		31	14				25.00	50.00	75.00																						25.00	50.00	62.50																		25.00					25.00							
H8064	002	0	1	04	01	H8064_002_0	12	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		31	14				7.00	14.00	21.00																						0.00	0.00	0.00																		7.00					7.00							
H8091	001	0	1	04	01	H8091_001_0	11	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	34		90							1	34		90							34		34					11.00		27.50																						11.00		27.50																		11.00					11.00							
H8091	001	0	1	04	01	H8091_001_0	11	3	Preferred Brand	1	4	000001	1	1	110100000010101000000001	34		90							1	34		90							34				34	14					39.71	25		25																					25		25																	25							25			
H8091	001	0	1	04	01	H8091_001_0	11	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	34		90							1	34		90							34		34					2.00		3.00																						2.00		3.00																		2.00					2.00							
H8091	001	0	1	04	01	H8091_001_0	11	5	Specialty Tier	1	4	010010	1	1	110100000010101000000101	34		90							1	34		90							34		34		34	14					354.35	25		25																					25		25																	25				25			25			
H8091	001	0	1	04	01	H8091_001_0	11	4	Non-Preferred Brand	1	4	100000	1	1	110100000010101000000001	34		90							1	34		90							34				34	14					94.61	42		42																					42		42																	42							42			
H8091	002	0	1	04	01	H8091_002_0	11	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	34		90							1	34		90							34		34					2.00		3.00																						2.00		3.00																		2.00					2.00							
H8091	002	0	1	04	01	H8091_002_0	11	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	34		90							1	34		90							34		34					11.00		27.50																						11.00		27.50																		11.00					11.00							
H8091	002	0	1	04	01	H8091_002_0	11	3	Preferred Brand	1	4	000001	1	1	110100000010101000000001	34		90							1	34		90							34				34	14					39.71	25		25																					25		25																	25							25			
H8091	002	0	1	04	01	H8091_002_0	11	4	Non-Preferred Brand	1	4	100000	1	1	110100000010101000000001	34		90							1	34		90							34				34	14					94.61	42		42																					42		42																	42							42			
H8091	002	0	1	04	01	H8091_002_0	11	5	Specialty Tier	1	4	010010	1	1	110100000010101000000101	34		90							1	34		90							34		34		34	14					354.35	25		25																					25		25																	25				25			25			
H8098	001	0	1	09	04	H8098_001_0	6	5	Specialty Tier	1	4	010010	1	1	110100000010111000000111	31		90							1	31	60	90							31		34	14	34	14					100.00	33		33																					33	33	33																	33				33			33			
H8098	001	0	1	09	04	H8098_001_0	6	3	Preferred Brand	1	4	010001	1	2	110100000010111000000111	31		90							1	31	60	90							31		34	14	34	14		45.00		135.00																						45.00	90.00	135.00																		45.00					45.00			45.00				
H8098	001	0	1	09	04	H8098_001_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110100000010111000000001	31		90							1	31	60	90							31				34	14		95.00		285.00																						95.00	190.00	285.00																		95.00								95.00				
H8098	001	0	1	09	04	H8098_001_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14				15.00		45.00																						15.00	30.00	30.00																		15.00					15.00							
H8098	001	0	1	09	04	H8098_001_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010111000000110	31		90							1	31	60	90							31		34	14				6.00		18.00																						6.00	12.00	12.00																		6.00					6.00							
H8130	001	0	1	01	01	H8130_001_0	7	4	Specialty Tier	1	4	010010	1	1	110000000010100000000111	31										31									31		31	14	31	14					442.01	25																							25																			25				25			25			
H8130	001	0	1	01	01	H8130_001_0	7	1	Generic	3	4	010000	1	2	011100000010111000000110	31	60	90							1	31	60	90							31		31	14				0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00					1		
H8130	001	0	1	01	01	H8130_001_0	7	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	31	60	90							1	31	60	90							31				31	14		0.00	0.00	0.00																						0.00	0.00	0.00																		0.00								0.00				
H8130	001	0	1	01	01	H8130_001_0	7	1	Generic	1	4	010000	1	2	011100000010111000000110	31	60	90							1	31	60	90							31		31	14				0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00							
H8130	001	0	1	01	01	H8130_001_0	7	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	31	60	90							1	31	60	90							31				31	14		95.00	190.00	285.00																						95.00	190.00	285.00																		95.00								95.00				
H8145	001	0	1	09	04	H8145_001_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00				
H8145	001	0	1	09	04	H8145_001_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H8145	001	0	1	09	04	H8145_001_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H8145	001	0	1	09	04	H8145_001_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		43.00		129.00																													43.00		119.00					43.00		129.00				43.00					43.00			43.00				
H8145	001	0	1	09	04	H8145_001_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					731.00	33																														33							33					33				33			33			
H8145	001	0	1	09	04	H8145_001_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00		2	3	1
H8145	001	0	1	09	04	H8145_001_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H8145	001	0	1	09	04	H8145_001_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		43.00		129.00																													43.00		119.00					43.00		129.00				43.00					43.00			43.00		2	2	
H8145	001	0	1	09	04	H8145_001_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00		2	3	
H8145	001	0	1	09	04	H8145_001_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					838.00	33																														33							33					33				33			33	2	3	
H8145	003	0	1	09	04	H8145_003_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H8145	003	0	1	09	04	H8145_003_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H8145	003	0	1	09	04	H8145_003_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H8145	003	0	1	09	04	H8145_003_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H8145	003	0	1	09	04	H8145_003_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					657.00	33																														33							33					33				33			33			
H8145	003	0	1	09	04	H8145_003_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H8145	003	0	1	09	04	H8145_003_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H8145	003	0	1	09	04	H8145_003_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					769.00	33																														33							33					33				33			33	2	3	
H8145	003	0	1	09	04	H8145_003_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H8145	003	0	1	09	04	H8145_003_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H8145	004	0	1	09	04	H8145_004_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H8145	004	0	1	09	04	H8145_004_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H8145	004	0	1	09	04	H8145_004_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					664.00	33																														33							33					33				33			33			
H8145	004	0	1	09	04	H8145_004_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H8145	004	0	1	09	04	H8145_004_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H8145	004	0	1	09	04	H8145_004_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H8145	004	0	1	09	04	H8145_004_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H8145	004	0	1	09	04	H8145_004_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					788.00	33																														33							33					33				33			33	2	3	
H8145	004	0	1	09	04	H8145_004_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H8145	004	0	1	09	04	H8145_004_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H8145	005	0	1	09	04	H8145_005_0	5	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H8145	005	0	1	09	04	H8145_005_0	5	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		42.00		126.00																													42.00		116.00					42.00		126.00				42.00					42.00			42.00		2	2	
H8145	005	0	1	09	04	H8145_005_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00		2	3	1
H8145	005	0	1	09	04	H8145_005_0	5	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					930.00	33																														33							33					33				33			33			
H8145	005	0	1	09	04	H8145_005_0	5	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H8145	005	0	1	09	04	H8145_005_0	5	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		42.00		126.00																													42.00		116.00					42.00		126.00				42.00					42.00			42.00				
H8145	005	0	1	09	04	H8145_005_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H8145	005	0	1	09	04	H8145_005_0	5	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1102.00	33																														33							33					33				33			33	2	3	
H8145	006	0	1	09	04	H8145_006_0	5	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					964.00	33																														33							33					33				33			33	2	3	
H8145	006	0	1	09	04	H8145_006_0	5	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H8145	006	0	1	09	04	H8145_006_0	5	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		41.00		123.00																													41.00		113.00					41.00		123.00				41.00					41.00			41.00		2	2	
H8145	006	0	1	09	04	H8145_006_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00		2	3	1
H8145	006	0	1	09	04	H8145_006_0	5	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					794.00	33																														33							33					33				33			33			
H8145	006	0	1	09	04	H8145_006_0	5	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H8145	006	0	1	09	04	H8145_006_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H8145	006	0	1	09	04	H8145_006_0	5	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		41.00		123.00																													41.00		113.00					41.00		123.00				41.00					41.00			41.00				
H8145	007	0	1	09	04	H8145_007_0	5	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1022.00	33																														33							33					33				33			33	2	3	
H8145	007	0	1	09	04	H8145_007_0	5	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H8145	007	0	1	09	04	H8145_007_0	5	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		42.00		126.00																													42.00		116.00					42.00		126.00				42.00					42.00			42.00		2	2	
H8145	007	0	1	09	04	H8145_007_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00		2	3	1
H8145	007	0	1	09	04	H8145_007_0	5	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					771.00	33																														33							33					33				33			33			
H8145	007	0	1	09	04	H8145_007_0	5	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H8145	007	0	1	09	04	H8145_007_0	5	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		42.00		126.00																													42.00		116.00					42.00		126.00				42.00					42.00			42.00				
H8145	007	0	1	09	04	H8145_007_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H8145	008	0	1	09	04	H8145_008_0	5	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					579.00	33																														33							33					33				33			33	2	3	
H8145	008	0	1	09	04	H8145_008_0	5	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H8145	008	0	1	09	04	H8145_008_0	5	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H8145	008	0	1	09	04	H8145_008_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00		2	3	1
H8145	008	0	1	09	04	H8145_008_0	5	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					494.00	33																														33							33					33				33			33			
H8145	008	0	1	09	04	H8145_008_0	5	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H8145	008	0	1	09	04	H8145_008_0	5	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H8145	008	0	1	09	04	H8145_008_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H8145	009	0	1	09	04	H8145_009_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H8145	009	0	1	09	04	H8145_009_0	5	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H8145	009	0	1	09	04	H8145_009_0	5	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H8145	009	0	1	09	04	H8145_009_0	5	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					732.00	33																														33							33					33				33			33			
H8145	009	0	1	09	04	H8145_009_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00		2	3	1
H8145	009	0	1	09	04	H8145_009_0	5	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H8145	009	0	1	09	04	H8145_009_0	5	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H8145	009	0	1	09	04	H8145_009_0	5	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					830.00	33																														33							33					33				33			33	2	3	
H8145	011	0	1	09	04	H8145_011_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H8145	011	0	1	09	04	H8145_011_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H8145	011	0	1	09	04	H8145_011_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1049.00	33																														33							33					33				33			33	2	3	
H8145	011	0	1	09	04	H8145_011_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H8145	011	0	1	09	04	H8145_011_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H8145	011	0	1	09	04	H8145_011_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H8145	011	0	1	09	04	H8145_011_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H8145	011	0	1	09	04	H8145_011_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					956.00	33																														33							33					33				33			33			
H8145	011	0	1	09	04	H8145_011_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H8145	011	0	1	09	04	H8145_011_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H8145	012	0	1	09	04	H8145_012_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H8145	012	0	1	09	04	H8145_012_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H8145	012	0	1	09	04	H8145_012_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H8145	012	0	1	09	04	H8145_012_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		13.00		39.00																													0.00		0.00					13.00		39.00				13.00					13.00			13.00		2	2	
H8145	012	0	1	09	04	H8145_012_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1062.00	33																														33							33					33				33			33	2	3	
H8145	012	0	1	09	04	H8145_012_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					922.00	33																														33							33					33				33			33			
H8145	012	0	1	09	04	H8145_012_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H8145	012	0	1	09	04	H8145_012_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H8145	012	0	1	09	04	H8145_012_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		13.00		39.00																													0.00		0.00					13.00		39.00				13.00					13.00			13.00				
H8145	012	0	1	09	04	H8145_012_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H8145	020	0	1	09	04	H8145_020_0	8	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					711.00	33																														33							33					33				33			33	2	3	
H8145	020	0	1	09	04	H8145_020_0	8	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H8145	020	0	1	09	04	H8145_020_0	8	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		44.00		132.00																													44.00		122.00					44.00		132.00				44.00					44.00			44.00		2	2	
H8145	020	0	1	09	04	H8145_020_0	8	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H8145	020	0	1	09	04	H8145_020_0	8	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H8145	020	0	1	09	04	H8145_020_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					621.00	33																														33							33					33				33			33			
H8145	020	0	1	09	04	H8145_020_0	8	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H8145	020	0	1	09	04	H8145_020_0	8	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		44.00		132.00																													44.00		122.00					44.00		132.00				44.00					44.00			44.00				
H8145	020	0	1	09	04	H8145_020_0	8	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H8145	020	0	1	09	04	H8145_020_0	8	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H8145	021	0	1	09	04	H8145_021_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1021.00	33																														33							33					33				33			33	2	3	
H8145	021	0	1	09	04	H8145_021_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H8145	021	0	1	09	04	H8145_021_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H8145	021	0	1	09	04	H8145_021_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H8145	021	0	1	09	04	H8145_021_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H8145	021	0	1	09	04	H8145_021_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					881.00	33																														33							33					33				33			33			
H8145	021	0	1	09	04	H8145_021_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H8145	021	0	1	09	04	H8145_021_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H8145	021	0	1	09	04	H8145_021_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H8145	021	0	1	09	04	H8145_021_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H8145	032	0	1	09	04	H8145_032_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H8145	032	0	1	09	04	H8145_032_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H8145	032	0	1	09	04	H8145_032_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H8145	032	0	1	09	04	H8145_032_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H8145	032	0	1	09	04	H8145_032_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					763.00	33																														33							33					33				33			33	2	3	
H8145	032	0	1	09	04	H8145_032_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H8145	032	0	1	09	04	H8145_032_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H8145	032	0	1	09	04	H8145_032_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H8145	032	0	1	09	04	H8145_032_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H8145	032	0	1	09	04	H8145_032_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					660.00	33																														33							33					33				33			33			
H8145	041	0	1	09	04	H8145_041_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H8145	041	0	1	09	04	H8145_041_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H8145	041	0	1	09	04	H8145_041_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					992.00	33																														33							33					33				33			33	2	3	
H8145	041	0	1	09	04	H8145_041_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H8145	041	0	1	09	04	H8145_041_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H8145	041	0	1	09	04	H8145_041_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H8145	041	0	1	09	04	H8145_041_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H8145	041	0	1	09	04	H8145_041_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					856.00	33																														33							33					33				33			33			
H8145	041	0	1	09	04	H8145_041_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H8145	041	0	1	09	04	H8145_041_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H8145	049	0	1	09	04	H8145_049_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H8145	049	0	1	09	04	H8145_049_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H8145	049	0	1	09	04	H8145_049_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H8145	049	0	1	09	04	H8145_049_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		14.00		42.00																													0.00		0.00					14.00		42.00				14.00					14.00			14.00		2	2	
H8145	049	0	1	09	04	H8145_049_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					851.00	33																														33							33					33				33			33	2	3	
H8145	049	0	1	09	04	H8145_049_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					728.00	33																														33							33					33				33			33			
H8145	049	0	1	09	04	H8145_049_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H8145	049	0	1	09	04	H8145_049_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H8145	049	0	1	09	04	H8145_049_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		14.00		42.00																													0.00		0.00					14.00		42.00				14.00					14.00			14.00				
H8145	049	0	1	09	04	H8145_049_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H8145	051	0	1	09	04	H8145_051_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H8145	051	0	1	09	04	H8145_051_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H8145	051	0	1	09	04	H8145_051_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H8145	051	0	1	09	04	H8145_051_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H8145	051	0	1	09	04	H8145_051_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					693.00	33																														33							33					33				33			33			
H8145	051	0	1	09	04	H8145_051_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H8145	051	0	1	09	04	H8145_051_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H8145	051	0	1	09	04	H8145_051_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H8145	051	0	1	09	04	H8145_051_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H8145	051	0	1	09	04	H8145_051_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					822.00	33																														33							33					33				33			33	2	3	
H8145	052	0	1	09	04	H8145_052_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H8145	052	0	1	09	04	H8145_052_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H8145	052	0	1	09	04	H8145_052_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					805.00	33																														33							33					33				33			33	2	3	
H8145	052	0	1	09	04	H8145_052_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H8145	052	0	1	09	04	H8145_052_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H8145	052	0	1	09	04	H8145_052_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H8145	052	0	1	09	04	H8145_052_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H8145	052	0	1	09	04	H8145_052_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					699.00	33																														33							33					33				33			33			
H8145	052	0	1	09	04	H8145_052_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H8145	052	0	1	09	04	H8145_052_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H8145	053	0	1	09	04	H8145_053_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H8145	053	0	1	09	04	H8145_053_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H8145	053	0	1	09	04	H8145_053_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H8145	053	0	1	09	04	H8145_053_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H8145	053	0	1	09	04	H8145_053_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					898.00	33																														33							33					33				33			33	2	3	
H8145	053	0	1	09	04	H8145_053_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					772.00	33																														33							33					33				33			33			
H8145	053	0	1	09	04	H8145_053_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H8145	053	0	1	09	04	H8145_053_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H8145	053	0	1	09	04	H8145_053_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H8145	053	0	1	09	04	H8145_053_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H8145	061	0	1	09	04	H8145_061_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					782.00	33																														33							33					33				33			33	2	3	
H8145	061	0	1	09	04	H8145_061_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H8145	061	0	1	09	04	H8145_061_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H8145	061	0	1	09	04	H8145_061_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H8145	061	0	1	09	04	H8145_061_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H8145	061	0	1	09	04	H8145_061_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					675.00	33																														33							33					33				33			33			
H8145	061	0	1	09	04	H8145_061_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H8145	061	0	1	09	04	H8145_061_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H8145	061	0	1	09	04	H8145_061_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H8145	061	0	1	09	04	H8145_061_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H8145	063	0	1	09	04	H8145_063_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H8145	063	0	1	09	04	H8145_063_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1012.00	33																														33							33					33				33			33	2	3	
H8145	063	0	1	09	04	H8145_063_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H8145	063	0	1	09	04	H8145_063_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H8145	063	0	1	09	04	H8145_063_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		2.00		6.00																													0.00		0.00					2.00		6.00				2.00					2.00			2.00		2	3	
H8145	063	0	1	09	04	H8145_063_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					869.00	33																														33							33					33				33			33			
H8145	063	0	1	09	04	H8145_063_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H8145	063	0	1	09	04	H8145_063_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H8145	063	0	1	09	04	H8145_063_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H8145	063	0	1	09	04	H8145_063_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		2.00		6.00																													0.00		0.00					2.00		6.00				2.00					2.00			2.00				
H8145	069	0	1	09	04	H8145_069_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H8145	069	0	1	09	04	H8145_069_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H8145	069	0	1	09	04	H8145_069_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H8145	069	0	1	09	04	H8145_069_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H8145	069	0	1	09	04	H8145_069_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1069.00	33																														33							33					33				33			33	2	3	
H8145	069	0	1	09	04	H8145_069_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H8145	069	0	1	09	04	H8145_069_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H8145	069	0	1	09	04	H8145_069_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H8145	069	0	1	09	04	H8145_069_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H8145	069	0	1	09	04	H8145_069_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					949.00	33																														33							33					33				33			33			
H8145	071	0	1	09	04	H8145_071_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					819.00	33																														33							33					33				33			33			
H8145	071	0	1	09	04	H8145_071_0	8	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H8145	071	0	1	09	04	H8145_071_0	8	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H8145	071	0	1	09	04	H8145_071_0	8	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H8145	071	0	1	09	04	H8145_071_0	8	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					971.00	33																														33							33					33				33			33	2	3	
H8145	071	0	1	09	04	H8145_071_0	8	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H8145	071	0	1	09	04	H8145_071_0	8	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H8145	071	0	1	09	04	H8145_071_0	8	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H8145	071	0	1	09	04	H8145_071_0	8	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H8145	071	0	1	09	04	H8145_071_0	8	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H8145	075	0	1	09	04	H8145_075_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H8145	075	0	1	09	04	H8145_075_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H8145	075	0	1	09	04	H8145_075_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H8145	075	0	1	09	04	H8145_075_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H8145	075	0	1	09	04	H8145_075_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					492.00	33																														33							33					33				33			33	2	3	
H8145	075	0	1	09	04	H8145_075_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					445.00	33																														33							33					33				33			33			
H8145	075	0	1	09	04	H8145_075_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H8145	075	0	1	09	04	H8145_075_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H8145	075	0	1	09	04	H8145_075_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H8145	075	0	1	09	04	H8145_075_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H8145	078	0	1	09	04	H8145_078_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		83.00		249.00																													83.00		239.00					83.00		249.00				83.00					83.00			83.00		2	3	
H8145	078	0	1	09	04	H8145_078_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		42.00		126.00																													42.00		116.00					42.00		126.00				42.00					42.00			42.00		2	2	
H8145	078	0	1	09	04	H8145_078_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H8145	078	0	1	09	04	H8145_078_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00		2	3	1
H8145	078	0	1	09	04	H8145_078_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					830.00	33																														33							33					33				33			33			
H8145	078	0	1	09	04	H8145_078_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		83.00		249.00																													83.00		239.00					83.00		249.00				83.00					83.00			83.00				
H8145	078	0	1	09	04	H8145_078_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		42.00		126.00																													42.00		116.00					42.00		126.00				42.00					42.00			42.00				
H8145	078	0	1	09	04	H8145_078_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H8145	078	0	1	09	04	H8145_078_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H8145	078	0	1	09	04	H8145_078_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					985.00	33																														33							33					33				33			33	2	3	
H8145	079	0	1	09	04	H8145_079_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					724.00	33																														33							33					33				33			33	2	3	
H8145	079	0	1	09	04	H8145_079_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H8145	079	0	1	09	04	H8145_079_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H8145	079	0	1	09	04	H8145_079_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H8145	079	0	1	09	04	H8145_079_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H8145	079	0	1	09	04	H8145_079_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					645.00	33																														33							33					33				33			33			
H8145	079	0	1	09	04	H8145_079_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H8145	079	0	1	09	04	H8145_079_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H8145	079	0	1	09	04	H8145_079_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H8145	079	0	1	09	04	H8145_079_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H8145	084	0	1	09	04	H8145_084_0	9	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H8145	084	0	1	09	04	H8145_084_0	9	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		39.00		117.00																													39.00		107.00					39.00		117.00				39.00					39.00			39.00		2	2	
H8145	084	0	1	09	04	H8145_084_0	9	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H8145	084	0	1	09	04	H8145_084_0	9	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					677.00	33																														33							33					33				33			33	2	3	
H8145	084	0	1	09	04	H8145_084_0	9	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		39.00		117.00																													39.00		107.00					39.00		117.00				39.00					39.00			39.00				
H8145	084	0	1	09	04	H8145_084_0	9	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H8145	084	0	1	09	04	H8145_084_0	9	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H8145	084	0	1	09	04	H8145_084_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					596.00	33																														33							33					33				33			33			
H8145	084	0	1	09	04	H8145_084_0	9	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H8145	084	0	1	09	04	H8145_084_0	9	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H8145	087	0	1	09	04	H8145_087_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					936.00	33																														33							33					33				33			33	2	3	
H8145	087	0	1	09	04	H8145_087_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H8145	087	0	1	09	04	H8145_087_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H8145	087	0	1	09	04	H8145_087_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H8145	087	0	1	09	04	H8145_087_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00		2	3	1
H8145	087	0	1	09	04	H8145_087_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H8145	087	0	1	09	04	H8145_087_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					808.00	33																														33							33					33				33			33			
H8145	087	0	1	09	04	H8145_087_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H8145	087	0	1	09	04	H8145_087_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H8145	087	0	1	09	04	H8145_087_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00				
H8145	089	0	1	09	04	H8145_089_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00		2	3	1
H8145	089	0	1	09	04	H8145_089_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		42.00		126.00																													42.00		116.00					42.00		126.00				42.00					42.00			42.00				
H8145	089	0	1	09	04	H8145_089_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H8145	089	0	1	09	04	H8145_089_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H8145	089	0	1	09	04	H8145_089_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					755.00	33																														33							33					33				33			33	2	3	
H8145	089	0	1	09	04	H8145_089_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		84.00		252.00																													84.00		242.00					84.00		252.00				84.00					84.00			84.00				
H8145	089	0	1	09	04	H8145_089_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H8145	089	0	1	09	04	H8145_089_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		42.00		126.00																													42.00		116.00					42.00		126.00				42.00					42.00			42.00		2	2	
H8145	089	0	1	09	04	H8145_089_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		84.00		252.00																													84.00		242.00					84.00		252.00				84.00					84.00			84.00		2	3	
H8145	089	0	1	09	04	H8145_089_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					651.00	33																														33							33					33				33			33			
H8145	091	0	1	09	04	H8145_091_0	8	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H8145	091	0	1	09	04	H8145_091_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					565.00	33																														33							33					33				33			33			
H8145	091	0	1	09	04	H8145_091_0	8	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H8145	091	0	1	09	04	H8145_091_0	8	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H8145	091	0	1	09	04	H8145_091_0	8	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H8145	091	0	1	09	04	H8145_091_0	8	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H8145	091	0	1	09	04	H8145_091_0	8	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H8145	091	0	1	09	04	H8145_091_0	8	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					653.00	33																														33							33					33				33			33	2	3	
H8145	091	0	1	09	04	H8145_091_0	8	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H8145	091	0	1	09	04	H8145_091_0	8	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H8145	093	0	1	09	04	H8145_093_0	8	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H8145	093	0	1	09	04	H8145_093_0	8	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					669.00	33																														33							33					33				33			33	2	3	
H8145	093	0	1	09	04	H8145_093_0	8	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H8145	093	0	1	09	04	H8145_093_0	8	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H8145	093	0	1	09	04	H8145_093_0	8	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H8145	093	0	1	09	04	H8145_093_0	8	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					553.00	33																														33							33					33				33			33			
H8145	093	0	1	09	04	H8145_093_0	8	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H8145	093	0	1	09	04	H8145_093_0	8	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H8145	095	0	1	09	04	H8145_095_0	7	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		38.00		114.00																													38.00		104.00					38.00		114.00				38.00					38.00			38.00				
H8145	095	0	1	09	04	H8145_095_0	7	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H8145	095	0	1	09	04	H8145_095_0	7	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					885.00	33																														33							33					33				33			33			
H8145	095	0	1	09	04	H8145_095_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H8145	095	0	1	09	04	H8145_095_0	7	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		38.00		114.00																													38.00		104.00					38.00		114.00				38.00					38.00			38.00		2	2	
H8145	095	0	1	09	04	H8145_095_0	7	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H8145	095	0	1	09	04	H8145_095_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H8145	095	0	1	09	04	H8145_095_0	7	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1129.00	33																														33							33					33				33			33	2	3	
H8145	103	0	1	09	04	H8145_103_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H8145	103	0	1	09	04	H8145_103_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
H8145	103	0	1	09	04	H8145_103_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H8145	103	0	1	09	04	H8145_103_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H8145	103	0	1	09	04	H8145_103_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	1
H8145	103	0	1	09	04	H8145_103_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					666.00	33																														33							33					33				33			33			
H8145	103	0	1	09	04	H8145_103_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H8145	103	0	1	09	04	H8145_103_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H8145	103	0	1	09	04	H8145_103_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					798.00	33																														33							33					33				33			33	2	3	
H8145	103	0	1	09	04	H8145_103_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H8145	104	0	1	09	04	H8145_104_0	6	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1441.00	33																														33							33					33				33			33	2	3	
H8145	104	0	1	09	04	H8145_104_0	6	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H8145	104	0	1	09	04	H8145_104_0	6	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		39.00		117.00																													39.00		107.00					39.00		117.00				39.00					39.00			39.00		2	2	
H8145	104	0	1	09	04	H8145_104_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H8145	104	0	1	09	04	H8145_104_0	6	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1229.00	33																														33							33					33				33			33			
H8145	104	0	1	09	04	H8145_104_0	6	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H8145	104	0	1	09	04	H8145_104_0	6	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		39.00		117.00																													39.00		107.00					39.00		117.00				39.00					39.00			39.00				
H8145	104	0	1	09	04	H8145_104_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H8145	110	0	1	09	04	H8145_110_0	5	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H8145	110	0	1	09	04	H8145_110_0	5	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					849.00	33																														33							33					33				33			33	2	3	
H8145	110	0	1	09	04	H8145_110_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H8145	110	0	1	09	04	H8145_110_0	5	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		42.00		126.00																													42.00		116.00					42.00		126.00				42.00					42.00			42.00				
H8145	110	0	1	09	04	H8145_110_0	5	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H8145	110	0	1	09	04	H8145_110_0	5	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					704.00	33																														33							33					33				33			33			
H8145	110	0	1	09	04	H8145_110_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00		2	3	1
H8145	110	0	1	09	04	H8145_110_0	5	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		42.00		126.00																													42.00		116.00					42.00		126.00				42.00					42.00			42.00		2	2	
H8145	122	0	1	09	04	H8145_122_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00		2	3	
H8145	122	0	1	09	04	H8145_122_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		43.00		129.00																													43.00		119.00					43.00		129.00				43.00					43.00			43.00		2	2	
H8145	122	0	1	09	04	H8145_122_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H8145	122	0	1	09	04	H8145_122_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00		2	3	1
H8145	122	0	1	09	04	H8145_122_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					847.00	33																														33							33					33				33			33	2	3	
H8145	122	0	1	09	04	H8145_122_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00				
H8145	122	0	1	09	04	H8145_122_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		43.00		129.00																													43.00		119.00					43.00		129.00				43.00					43.00			43.00				
H8145	122	0	1	09	04	H8145_122_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H8145	122	0	1	09	04	H8145_122_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H8145	122	0	1	09	04	H8145_122_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					739.00	33																														33							33					33				33			33			
H8145	123	0	1	09	04	H8145_123_0	8	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					660.00	33																														33							33					33				33			33	2	3	
H8145	123	0	1	09	04	H8145_123_0	8	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		89.00		267.00																													89.00		257.00					89.00		267.00				89.00					89.00			89.00		2	3	
H8145	123	0	1	09	04	H8145_123_0	8	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H8145	123	0	1	09	04	H8145_123_0	8	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
H8145	123	0	1	09	04	H8145_123_0	8	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00		2	3	1
H8145	123	0	1	09	04	H8145_123_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					557.00	33																														33							33					33				33			33			
H8145	123	0	1	09	04	H8145_123_0	8	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		89.00		267.00																													89.00		257.00					89.00		267.00				89.00					89.00			89.00				
H8145	123	0	1	09	04	H8145_123_0	8	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H8145	123	0	1	09	04	H8145_123_0	8	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H8145	123	0	1	09	04	H8145_123_0	8	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
H8145	124	0	1	09	04	H8145_124_0	8	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00				
H8145	124	0	1	09	04	H8145_124_0	8	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		13.00		39.00																													0.00		0.00					13.00		39.00				13.00					13.00			13.00				
H8145	124	0	1	09	04	H8145_124_0	8	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					691.00	33																														33							33					33				33			33	2	3	
H8145	124	0	1	09	04	H8145_124_0	8	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00		2	3	
H8145	124	0	1	09	04	H8145_124_0	8	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		43.00		129.00																													43.00		119.00					43.00		129.00				43.00					43.00			43.00		2	2	
H8145	124	0	1	09	04	H8145_124_0	8	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		13.00		39.00																													0.00		0.00					13.00		39.00				13.00					13.00			13.00		2	2	
H8145	124	0	1	09	04	H8145_124_0	8	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00		2	3	1
H8145	124	0	1	09	04	H8145_124_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					573.00	33																														33							33					33				33			33			
H8145	124	0	1	09	04	H8145_124_0	8	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00				
H8145	124	0	1	09	04	H8145_124_0	8	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		43.00		129.00																													43.00		119.00					43.00		129.00				43.00					43.00			43.00				
H8145	125	0	1	09	04	H8145_125_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H8145	125	0	1	09	04	H8145_125_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00		2	3	
H8145	125	0	1	09	04	H8145_125_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		42.00		126.00																													42.00		116.00					42.00		126.00				42.00					42.00			42.00		2	2	
H8145	125	0	1	09	04	H8145_125_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H8145	125	0	1	09	04	H8145_125_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1038.00	33																														33							33					33				33			33	2	3	
H8145	125	0	1	09	04	H8145_125_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					892.00	33																														33							33					33				33			33			
H8145	125	0	1	09	04	H8145_125_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00				
H8145	125	0	1	09	04	H8145_125_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		42.00		126.00																													42.00		116.00					42.00		126.00				42.00					42.00			42.00				
H8145	125	0	1	09	04	H8145_125_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H8145	125	0	1	09	04	H8145_125_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00		2	3	1
H8145	138	0	1	09	04	H8145_138_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H8145	138	0	1	09	04	H8145_138_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H8145	138	0	1	09	04	H8145_138_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		35.00		105.00																													35.00		95.00					35.00		105.00				35.00					35.00			35.00				
H8145	138	0	1	09	04	H8145_138_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		70.00		210.00																													70.00		200.00					70.00		210.00				70.00					70.00			70.00				
H8145	138	0	1	09	04	H8145_138_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1129.00	26																														26							26					26				26			26			
H8145	138	0	1	09	04	H8145_138_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H8145	138	0	1	09	04	H8145_138_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H8145	138	0	1	09	04	H8145_138_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		35.00		105.00																													35.00		95.00					35.00		105.00				35.00					35.00			35.00		2	2	
H8145	138	0	1	09	04	H8145_138_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		70.00		210.00																													70.00		200.00					70.00		210.00				70.00					70.00			70.00		2	3	
H8145	138	0	1	09	04	H8145_138_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1365.00	26																														26							26					26				26			26	2	3	
H8145	139	0	1	09	04	H8145_139_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H8145	139	0	1	09	04	H8145_139_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H8145	139	0	1	09	04	H8145_139_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H8145	139	0	1	09	04	H8145_139_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00		2	3	1
H8145	139	0	1	09	04	H8145_139_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H8145	139	0	1	09	04	H8145_139_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H8145	139	0	1	09	04	H8145_139_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H8145	139	0	1	09	04	H8145_139_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					786.00	33																														33							33					33				33			33	2	3	
H8145	139	0	1	09	04	H8145_139_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H8145	139	0	1	09	04	H8145_139_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					697.00	33																														33							33					33				33			33			
H8145	154	0	1	09	04	H8145_154_0	5	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					851.00	33																														33							33					33				33			33	2	3	
H8145	154	0	1	09	04	H8145_154_0	5	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H8145	154	0	1	09	04	H8145_154_0	5	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H8145	154	0	1	09	04	H8145_154_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00		2	3	1
H8145	154	0	1	09	04	H8145_154_0	5	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					718.00	33																														33							33					33				33			33			
H8145	154	0	1	09	04	H8145_154_0	5	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H8145	154	0	1	09	04	H8145_154_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H8145	154	0	1	09	04	H8145_154_0	5	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H8189	001	0	1	01	01	H8189_001_0	8	1	Generic	1	4	010000	1	2	010100000010001000000100	30		90							2			90							30		31					0.00		0.00																								0.00																		0.00					0.00							
H8189	001	0	1	01	01	H8189_001_0	8	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	7		45.00		45.00																								45.00																		45.00								45.00				
H8189	001	0	1	01	01	H8189_001_0	8	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							2			90							30				31	7		95.00		95.00																								95.00																		95.00								95.00				
H8189	001	0	1	01	01	H8189_001_0	8	4	Injectable Drugs	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	7		95.00		95.00																								95.00																		95.00								95.00				
H8393	001	0	1	04	01	H8393_001_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													4.00		12.00						9.00		27.00						4.00		12.00																		9.00					9.00							
H8393	001	0	1	04	01	H8393_001_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													9.00		27.00						9.00		27.00						9.00		27.00																		9.00					9.00							
H8393	001	0	1	04	01	H8393_001_0	6	5	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													574.60	33							574.60	33																										33				33			33			
H8393	001	0	1	04	01	H8393_001_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										95.00		285.00						95.00		285.00						95.00		285.00																		95.00					95.00			95.00				
H8393	001	0	1	04	01	H8393_001_0	6	3	Preferred Brand	1	4	000001	1	2	100010110110101000000001				30		90	30		90	2	30		90							30				31	14										45.00		135.00						45.00		135.00						45.00		135.00																		45.00								45.00				
H8552	001	0	1	04	01	H8552_001_0	8	2	Non-Preferred Generic	1	3	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				14.00	28.00	42.00																						14.00	28.00	21.00																		14.00					14.00							
H8552	001	0	1	04	01	H8552_001_0	8	1	Preferred Generic	1	3	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				6.00	12.00	18.00																						6.00	12.00	9.00																		6.00					6.00							
H8552	001	0	1	04	01	H8552_001_0	8	3	Preferred Brand	1	3	010001		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		42.00	84.00	126.00																						42.00	84.00	105.00																		42.00					42.00			42.00				
H8552	001	0	1	04	01	H8552_001_0	8	4	Non-Preferred Brand	1	3	110000		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H8552	001	0	1	04	01	H8552_001_0	8	5	Injectable Drugs	1	3	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					103.00	33	33	33																					33	33	33																	33				33			33			
H8552	001	0	1	04	01	H8552_001_0	8	6	Specialty Tier	1	3	010010		1	110000000010100000000111	30										30									30		34	14	34	14					685.00	33																							33																			33				33			33			
H8552	002	0	1	04	01	H8552_002_0	9	2	Non-Preferred Generic	1	3	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				17.00	34.00	51.00																						17.00	34.00	25.50																		17.00					17.00							
H8552	002	0	1	04	01	H8552_002_0	9	1	Preferred Generic	1	3	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				5.00	10.00	15.00																						5.00	10.00	7.50																		5.00					5.00							
H8552	002	0	1	04	01	H8552_002_0	9	3	Preferred Brand	1	3	010001		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00					45.00			45.00				
H8552	002	0	1	04	01	H8552_002_0	9	6	Specialty Tier	1	3	010010		1	110000000010100000000111	30										30									30		34	14	34	14					685.00	33																							33																			33				33			33			
H8552	002	0	1	04	01	H8552_002_0	9	5	Injectable Drugs	1	3	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					103.00	33	33	33																					33	33	33																	33				33			33			
H8552	002	0	1	04	01	H8552_002_0	9	4	Non-Preferred Brand	1	3	110000		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H8552	003	0	1	04	01	H8552_003_0	9	1	Preferred Generic	1	3	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				4.00	8.00	12.00																						4.00	8.00	6.00																		4.00					4.00							
H8552	003	0	1	04	01	H8552_003_0	9	2	Non-Preferred Generic	1	3	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				6.00	12.00	18.00																						6.00	12.00	9.00																		6.00					6.00							
H8552	003	0	1	04	01	H8552_003_0	9	5	Injectable Drugs	1	3	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					103.00	33	33	33																					33	33	33																	33				33			33			
H8552	003	0	1	04	01	H8552_003_0	9	4	Non-Preferred Brand	1	3	110000		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		90.00	180.00	270.00																						90.00	180.00	225.00																		90.00					90.00			90.00				
H8552	003	0	1	04	01	H8552_003_0	9	3	Preferred Brand	1	3	010001		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		40.00	80.00	120.00																						40.00	80.00	100.00																		40.00					40.00			40.00				
H8552	003	0	1	04	01	H8552_003_0	9	6	Specialty Tier	1	3	010010		1	110000000010100000000111	30										30									30		34	14	34	14					685.00	33																							33																			33				33			33			
H8552	006	0	1	04	01	H8552_006_0	9	6	Specialty Tier	1	3	010010		1	110000000010100000000111	30										30									30		34	14	34	14					685.00	33																							33																			33				33			33			
H8552	006	0	1	04	01	H8552_006_0	9	1	Preferred Generic	1	3	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				4.00	8.00	12.00																						4.00	8.00	6.00																		4.00					4.00							
H8552	006	0	1	04	01	H8552_006_0	9	2	Non-Preferred Generic	1	3	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				12.00	24.00	36.00																						12.00	24.00	18.00																		12.00					12.00							
H8552	006	0	1	04	01	H8552_006_0	9	3	Preferred Brand	1	3	010001		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		39.00	78.00	117.00																						39.00	78.00	97.50																		39.00					39.00			39.00				
H8552	006	0	1	04	01	H8552_006_0	9	4	Non-Preferred Brand	1	3	110000		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		91.00	182.00	273.00																						91.00	182.00	227.50																		91.00					91.00			91.00				
H8552	006	0	1	04	01	H8552_006_0	9	5	Injectable Drugs	1	3	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					103.00	33	33	33																					33	33	33																	33				33			33			
H8552	007	0	1	04	01	H8552_007_0	8	3	Preferred Brand	1	3	010001		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		39.00	78.00	117.00																						39.00	78.00	97.50																		39.00					39.00			39.00				
H8552	007	0	1	04	01	H8552_007_0	8	2	Non-Preferred Generic	1	3	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				9.00	18.00	27.00																						9.00	18.00	13.50																		9.00					9.00							
H8552	007	0	1	04	01	H8552_007_0	8	1	Preferred Generic	1	3	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				5.00	10.00	15.00																						5.00	10.00	7.50																		5.00					5.00							
H8552	007	0	1	04	01	H8552_007_0	8	4	Non-Preferred Brand	1	3	110000		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		90.00	180.00	270.00																						90.00	180.00	225.00																		90.00					90.00			90.00				
H8552	007	0	1	04	01	H8552_007_0	8	5	Injectable Drugs	1	3	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					103.00	33	33	33																					33	33	33																	33				33			33			
H8552	007	0	1	04	01	H8552_007_0	8	6	Specialty Tier	1	3	010010		1	110000000010100000000111	30										30									30		34	14	34	14					685.00	33																							33																			33				33			33			
H8552	008	0	1	04	01	H8552_008_0	9	1	Preferred Generic	1	3	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				4.00	8.00	12.00																						4.00	8.00	6.00																		4.00					4.00							
H8552	008	0	1	04	01	H8552_008_0	9	2	Non-Preferred Generic	1	3	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				8.00	16.00	24.00																						8.00	16.00	12.00																		8.00					8.00							
H8552	008	0	1	04	01	H8552_008_0	9	3	Preferred Brand	1	3	010001		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		40.00	80.00	120.00																						40.00	80.00	100.00																		40.00					40.00			40.00				
H8552	008	0	1	04	01	H8552_008_0	9	4	Non-Preferred Brand	1	3	110000		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		90.00	180.00	270.00																						90.00	180.00	225.00																		90.00					90.00			90.00				
H8552	008	0	1	04	01	H8552_008_0	9	5	Injectable Drugs	1	3	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					103.00	33	33	33																					33	33	33																	33				33			33			
H8552	008	0	1	04	01	H8552_008_0	9	6	Specialty Tier	1	3	010010		1	110000000010100000000111	30										30									30		34	14	34	14					685.00	33																							33																			33				33			33			
H8552	009	0	1	04	01	H8552_009_0	8	3	Preferred Brand	1	3	010001		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		40.00	80.00	120.00																						40.00	80.00	100.00																		40.00					40.00			40.00				
H8552	009	0	1	04	01	H8552_009_0	8	4	Non-Preferred Brand	1	3	110000		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		90.00	180.00	270.00																						90.00	180.00	225.00																		90.00					90.00			90.00				
H8552	009	0	1	04	01	H8552_009_0	8	1	Preferred Generic	1	3	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				4.00	8.00	12.00																						4.00	8.00	6.00																		4.00					4.00							
H8552	009	0	1	04	01	H8552_009_0	8	2	Non-Preferred Generic	1	3	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				9.00	18.00	27.00																						9.00	18.00	13.50																		9.00					9.00							
H8552	009	0	1	04	01	H8552_009_0	8	5	Injectable Drugs	1	3	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					103.00	33	33	33																					33	33	33																	33				33			33			
H8552	009	0	1	04	01	H8552_009_0	8	6	Specialty Tier	1	3	010010		1	110000000010100000000111	30										30									30		34	14	34	14					685.00	33																							33																			33				33			33			
H8552	011	0	1	04	01	H8552_011_0	8	4	Non-Preferred Brand	1	3	110000		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		90.00	180.00	270.00																						90.00	180.00	225.00																		90.00					90.00			90.00				
H8552	011	0	1	04	01	H8552_011_0	8	1	Preferred Generic	1	3	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				4.00	8.00	12.00																						4.00	8.00	6.00																		4.00					4.00							
H8552	011	0	1	04	01	H8552_011_0	8	2	Non-Preferred Generic	1	3	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				9.00	18.00	27.00																						9.00	18.00	13.50																		9.00					9.00							
H8552	011	0	1	04	01	H8552_011_0	8	3	Preferred Brand	1	3	010001		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		40.00	80.00	120.00																						40.00	80.00	100.00																		40.00					40.00			40.00				
H8552	011	0	1	04	01	H8552_011_0	8	5	Injectable Drugs	1	3	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					103.00	33	33	33																					33	33	33																	33				33			33			
H8552	011	0	1	04	01	H8552_011_0	8	6	Specialty Tier	1	3	010010		1	110000000010100000000111	30										30									30		34	14	34	14					685.00	33																							33																			33				33			33			
H8552	015	0	1	04	01	H8552_015_0	9	6	Specialty Tier	1	3	010010		1	110000000010100000000111	30										30									30		34	14	34	14					685.00	33																							33																			33				33			33			
H8552	015	0	1	04	01	H8552_015_0	9	4	Non-Preferred Brand	1	3	110000		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		90.00	180.00	270.00																						90.00	180.00	225.00																		90.00					90.00			90.00				
H8552	015	0	1	04	01	H8552_015_0	9	5	Injectable Drugs	1	3	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					103.00	33	33	33																					33	33	33																	33				33			33			
H8552	015	0	1	04	01	H8552_015_0	9	1	Preferred Generic	1	3	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				4.00	8.00	12.00																						4.00	8.00	6.00																		4.00					4.00							
H8552	015	0	1	04	01	H8552_015_0	9	2	Non-Preferred Generic	1	3	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				9.00	18.00	27.00																						9.00	18.00	13.50																		9.00					9.00							
H8552	015	0	1	04	01	H8552_015_0	9	3	Preferred Brand	1	3	010001		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		39.00	78.00	117.00																						39.00	78.00	97.50																		39.00					39.00			39.00				
H8552	017	0	1	04	01	H8552_017_0	9	3	Preferred Brand	1	3	010001		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		38.00	76.00	114.00																						38.00	76.00	95.00																		38.00					38.00			38.00				
H8552	017	0	1	04	01	H8552_017_0	9	2	Non-Preferred Generic	1	3	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				9.00	18.00	27.00																						9.00	18.00	13.50																		9.00					9.00							
H8552	017	0	1	04	01	H8552_017_0	9	1	Preferred Generic	1	3	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				4.00	8.00	12.00																						4.00	8.00	6.00																		4.00					4.00							
H8552	017	0	1	04	01	H8552_017_0	9	5	Injectable Drugs	1	3	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					103.00	33	33	33																					33	33	33																	33				33			33			
H8552	017	0	1	04	01	H8552_017_0	9	6	Specialty Tier	1	3	010010		1	110000000010100000000111	30										30									30		34	14	34	14					685.00	33																							33																			33				33			33			
H8552	017	0	1	04	01	H8552_017_0	9	4	Non-Preferred Brand	1	3	110000		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		85.00	170.00	255.00																						85.00	170.00	212.50																		85.00					85.00			85.00				
H8578	001	0	1	01	01	H8578_001_0	7	4	Specialty Tier	1	4	110001	3	1	110000000010100000000111	30										30									30		31	14	31	14					760.00	33																							33																			33				33			33			
H8578	001	0	1	01	01	H8578_001_0	7	1	Generic	3	4	010000	3	2	011100000010001000000110	30	60	90							1			90							30		31	14				10.00	20.00	30.00																								20.00																		10.00					10.00					1		
H8578	001	0	1	01	01	H8578_001_0	7	1	Generic	1	4	010000	3	2	011100000010001000000110	30	60	90							1			90							30		31	14				10.00	20.00	30.00																								20.00																		10.00					10.00							
H8578	001	0	1	01	01	H8578_001_0	7	2	Preferred Brand	1	4	000001	3	2	111100000010001000000001	30	60	90							1			90							30				31	14		35.00	70.00	105.00																								70.00																		35.00								35.00				
H8578	001	0	1	01	01	H8578_001_0	7	3	Non-Preferred Brand	1	4	100000	3	2	111100000010001000000001	30	60	90							1			90							30				31	14		65.00	130.00	195.00																								195.00																		65.00								65.00				
H8578	004	0	1	01	01	H8578_004_0	7	1	Generic	3	4	010000	3	2	011100000010001000000110	30	60	90							1			90							30		31	14				10.00	20.00	30.00																								20.00																		10.00					10.00					1		
H8578	004	0	1	01	01	H8578_004_0	7	1	Generic	1	4	010000	3	2	011100000010001000000110	30	60	90							1			90							30		31	14				10.00	20.00	30.00																								20.00																		10.00					10.00							
H8578	004	0	1	01	01	H8578_004_0	7	2	Preferred Brand	1	4	000001	3	2	111100000010001000000001	30	60	90							1			90							30				31	14		35.00	70.00	105.00																								70.00																		35.00								35.00				
H8578	004	0	1	01	01	H8578_004_0	7	3	Non-Preferred Brand	1	4	100000	3	2	111100000010001000000001	30	60	90							1			90							30				31	14		65.00	130.00	195.00																								195.00																		65.00								65.00				
H8578	004	0	1	01	01	H8578_004_0	7	4	Specialty Tier	1	4	110001	3	1	110000000010100000000111	30										30									30		31	14	31	14					1775.00	33																							33																			33				33			33			
H8578	007	0	1	01	01	H8578_007_0	9	4	Specialty Tier	1	4	110001	3	1	110000000010100000000111	30										30									30		31	14	31	14					1085.00	33																							33																			33				33			33			
H8578	007	0	1	01	01	H8578_007_0	9	1	Generic	3	4	010000	3	2	011100000010001000000110	30	60	90							1			90							30		31	14				10.00	20.00	30.00																								20.00																		10.00					10.00					1		
H8578	007	0	1	01	01	H8578_007_0	9	3	Non-Preferred Brand	1	4	100000	3	2	111100000010001000000001	30	60	90							1			90							30				31	14		65.00	130.00	195.00																								195.00																		65.00								65.00				
H8578	007	0	1	01	01	H8578_007_0	9	1	Generic	1	4	010000	3	2	011100000010001000000110	30	60	90							1			90							30		31	14				10.00	20.00	30.00																								20.00																		10.00					10.00							
H8578	007	0	1	01	01	H8578_007_0	9	2	Preferred Brand	1	4	000001	3	2	111100000010001000000001	30	60	90							1			90							30				31	14		35.00	70.00	105.00																								70.00																		35.00								35.00				
H8578	010	0	1	02	01	H8578_010_0	8	1	Generic	3	4	010000	3	2	011100000010001000000110	30	60	90							1			90							30		31	14				10.00	20.00	30.00																								20.00																		10.00					10.00					1		
H8578	010	0	1	02	01	H8578_010_0	8	3	Non-Preferred Brand	1	4	100000	3	2	111100000010001000000001	30	60	90							1			90							30				31	14		65.00	130.00	195.00																								195.00																		65.00								65.00				
H8578	010	0	1	02	01	H8578_010_0	8	4	Specialty Tier	1	4	110001	3	1	110000000010100000000111	30										30									30		31	14	31	14					1251.00	33																							33																			33				33			33			
H8578	010	0	1	02	01	H8578_010_0	8	2	Preferred Brand	1	4	000001	3	2	111100000010001000000001	30	60	90							1			90							30				31	14		35.00	70.00	105.00																								70.00																		35.00								35.00				
H8578	010	0	1	02	01	H8578_010_0	8	1	Generic	1	4	010000	3	2	011100000010001000000110	30	60	90							1			90							30		31	14				10.00	20.00	30.00																								20.00																		10.00					10.00							
H8604	001	0	1	04	01	H8604_001_0	11	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				8.00		24.00																								16.00																		8.00					8.00							
H8604	001	0	1	04	01	H8604_001_0	11	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				15.00		45.00																								30.00																		15.00					15.00							
H8604	001	0	1	04	01	H8604_001_0	11	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				15.00		45.00																								30.00																		15.00					15.00					1		
H8604	001	0	1	04	01	H8604_001_0	11	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							2			90							30				31	14		95.00		285.00																								190.00																		95.00								95.00				
H8604	001	0	1	04	01	H8604_001_0	11	5	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		31	14	31	14					1000.16	33																							33																			33				33			33			
H8604	001	0	1	04	01	H8604_001_0	11	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				8.00		24.00																								16.00																		8.00					8.00					1		
H8604	001	0	1	04	01	H8604_001_0	11	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		40.00		120.00																								80.00																		40.00								40.00				
H8604	003	0	1	04	01	H8604_003_0	14	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				15.00		45.00																								30.00																		15.00					15.00							
H8604	003	0	1	04	01	H8604_003_0	14	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							2			90							30				31	14		95.00		285.00																								190.00																		95.00								95.00				
H8604	003	0	1	04	01	H8604_003_0	14	5	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		31	14	31	14					1000.16	33																							33																			33				33			33			
H8604	003	0	1	04	01	H8604_003_0	14	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				8.00		24.00																								16.00																		8.00					8.00					1		
H8604	003	0	1	04	01	H8604_003_0	14	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				15.00		45.00																								30.00																		15.00					15.00					1		
H8604	003	0	1	04	01	H8604_003_0	14	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		40.00		120.00																								80.00																		40.00								40.00				
H8604	003	0	1	04	01	H8604_003_0	14	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				8.00		24.00																								16.00																		8.00					8.00							
H8604	005	0	1	04	01	H8604_005_0	11	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				10.00		30.00																								20.00																		10.00					10.00					1		
H8604	005	0	1	04	01	H8604_005_0	11	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				3.00		9.00																								6.00																		3.00					3.00							
H8604	005	0	1	04	01	H8604_005_0	11	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				10.00		30.00																								20.00																		10.00					10.00							
H8604	005	0	1	04	01	H8604_005_0	11	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		35.00		105.00																								70.00																		35.00								35.00				
H8604	005	0	1	04	01	H8604_005_0	11	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							2			90							30				31	14		95.00		285.00																								190.00																		95.00								95.00				
H8604	005	0	1	04	01	H8604_005_0	11	5	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		31	14	31	14					1023.52	33																							33																			33				33			33			
H8604	005	0	1	04	01	H8604_005_0	11	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				3.00		9.00																								6.00																		3.00					3.00					1		
H8604	006	0	1	04	01	H8604_006_0	14	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				10.00		30.00																								20.00																		10.00					10.00					1		
H8604	006	0	1	04	01	H8604_006_0	14	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				3.00		9.00																								6.00																		3.00					3.00					1		
H8604	006	0	1	04	01	H8604_006_0	14	5	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		31	14	31	14					1023.52	33																							33																			33				33			33			
H8604	006	0	1	04	01	H8604_006_0	14	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							2			90							30				31	14		95.00		285.00																								190.00																		95.00								95.00				
H8604	006	0	1	04	01	H8604_006_0	14	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				10.00		30.00																								20.00																		10.00					10.00							
H8604	006	0	1	04	01	H8604_006_0	14	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		35.00		105.00																								70.00																		35.00								35.00				
H8604	006	0	1	04	01	H8604_006_0	14	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				3.00		9.00																								6.00																		3.00					3.00							
H8644	003	0	1	04	01	H8644_003_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H8644	003	0	1	04	01	H8644_003_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H8644	003	0	1	04	01	H8644_003_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H8644	003	0	1	04	01	H8644_003_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H8644	003	0	1	04	01	H8644_003_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H8644	003	0	1	04	01	H8644_003_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H8644	003	0	1	04	01	H8644_003_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H8644	003	0	1	04	01	H8644_003_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H8644	003	0	1	04	01	H8644_003_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					696.00	33																														33							33					33				33			33			
H8644	003	0	1	04	01	H8644_003_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					747.00	33																														33							33					33				33			33	2	3	
H8644	005	0	1	04	01	H8644_005_0	7	5	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													673.00	25							683.00	25														25							25					25				25			25			
H8644	005	0	1	04	01	H8644_005_0	7	4	Non-Preferred Brand	1	4	110000	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													97.00	30		30					99.00	50		50												30		30					50		50			50				50			50			
H8644	005	0	1	04	01	H8644_005_0	7	3	Preferred Brand	1	4	000101	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													17.00	18		18					24.00	25		25												18		18					25		25			25				25			25			
H8644	005	0	1	04	01	H8644_005_0	7	2	Non-Preferred Generic	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										3.00		9.00						12.00		36.00													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H8644	005	0	1	04	01	H8644_005_0	7	3	Preferred Brand	3	4	000101	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													23.00	18		18					32.00	25		25												18		18					25		25			25				25			25	2	2	
H8644	005	0	1	04	01	H8644_005_0	7	4	Non-Preferred Brand	3	4	110000	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													124.00	30		30					126.00	50		50												30		30					50		50			50				50			50	2	3	
H8644	005	0	1	04	01	H8644_005_0	7	2	Non-Preferred Generic	3	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										3.00		9.00						12.00		36.00													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	3	
H8644	005	0	1	04	01	H8644_005_0	7	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										1.00		3.00						8.00		24.00													0.00		0.00					8.00		24.00				8.00					8.00			8.00				
H8644	005	0	1	04	01	H8644_005_0	7	5	Specialty Tier	3	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													756.00	25							768.00	25														25							25					25				25			25	2	3	
H8649	003	0	1	02	01	H8649_003_0	7	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													3.00		9.00						4.00		12.00						3.00		9.00																		4.00					4.00							
H8649	003	0	1	02	01	H8649_003_0	7	2	Non-Preferred Generic	1	4	000100	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													6.00		18.00						9.00		27.00						6.00		18.00																		9.00					9.00							
H8649	003	0	1	02	01	H8649_003_0	7	3	Preferred Brand	1	4	000001	1	2	100010110110101000000001				30		90	30		90	2	30		90							30				31	14										45.00		135.00						45.00		135.00						45.00		135.00																		45.00								45.00				
H8649	003	0	1	02	01	H8649_003_0	7	4	Non-Preferred Brand	1	4	100100	1	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										87.00		261.00						87.00		261.00						87.00		261.00																		87.00					87.00			87.00				
H8649	003	0	1	02	01	H8649_003_0	7	5	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													838.92	33							838.92	33																										33				33			33			
H8684	001	0	1	04	01	H8684_001_0	7	5	Specialty Tier	1	4	010010	1	1	111100000001000111111101	31	60	90							1				31	60	90	31	60	90		10	31		31	14					331.84	33	33	33																												33	33	33					33	33	33				33			33			33			
H8684	001	0	1	04	01	H8684_001_0	7	1	Preferred Generic	1	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					6.00	12.00	18.00																													6.00	12.00	12.00					6.00	12.00	18.00					6.00				6.00							
H8684	001	0	1	04	01	H8684_001_0	7	2	Non-Preferred Generic	1	4	000100	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					33.00	66.00	99.00																													33.00	66.00	66.00					33.00	66.00	99.00					33.00				33.00							
H8684	001	0	1	04	01	H8684_001_0	7	1	Preferred Generic	3	4	001000	1	2	011100000001000111111100	31	60	90							1				31	60	90	31	60	90		10	31					6.00	12.00	18.00																													6.00	12.00	12.00					6.00	12.00	18.00					6.00				6.00					1		
H8684	001	0	1	04	01	H8684_001_0	7	4	Non-Preferred Brand	1	4	100000	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		95.00	190.00	285.00																													95.00	190.00	190.00					95.00	190.00	285.00					95.00							95.00				
H8684	001	0	1	04	01	H8684_001_0	7	3	Preferred Brand	1	4	000001	1	2	111100000001000111111001	31	60	90							1				31	60	90	31	60	90		10			31	14		45.00	90.00	135.00																													45.00	90.00	90.00					45.00	90.00	135.00					45.00							45.00				
H8707	001	0	1	04	01	H8707_001_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					618.00	33																														33							33					33				33			33			
H8707	001	0	1	04	01	H8707_001_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H8707	001	0	1	04	01	H8707_001_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H8707	001	0	1	04	01	H8707_001_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H8707	001	0	1	04	01	H8707_001_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00		2	3	1
H8707	001	0	1	04	01	H8707_001_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					698.00	33																														33							33					33				33			33	2	3	
H8707	001	0	1	04	01	H8707_001_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H8707	001	0	1	04	01	H8707_001_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H8707	001	0	1	04	01	H8707_001_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H8707	001	0	1	04	01	H8707_001_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00				
H8707	003	0	1	04	01	H8707_003_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					912.00	33																														33							33					33				33			33	2	3	
H8707	003	0	1	04	01	H8707_003_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H8707	003	0	1	04	01	H8707_003_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H8707	003	0	1	04	01	H8707_003_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
H8707	003	0	1	04	01	H8707_003_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H8707	003	0	1	04	01	H8707_003_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					813.00	33																														33							33					33				33			33			
H8707	003	0	1	04	01	H8707_003_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H8707	003	0	1	04	01	H8707_003_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H8707	003	0	1	04	01	H8707_003_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
H8707	003	0	1	04	01	H8707_003_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H8748	001	0	1	01	01	H8748_001_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H8748	001	0	1	01	01	H8748_001_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H8748	001	0	1	01	01	H8748_001_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H8748	001	0	1	01	01	H8748_001_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H8748	001	0	1	01	01	H8748_001_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					549.00	33		33																														33							33			33				33			33			
H8748	002	0	1	01	01	H8748_002_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					609.00	33		33																														33							33			33				33			33			
H8748	002	0	1	01	01	H8748_002_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H8748	002	0	1	01	01	H8748_002_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H8748	002	0	1	01	01	H8748_002_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H8748	002	0	1	01	01	H8748_002_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H8748	003	0	1	02	01	H8748_003_0	8	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					514.00	33		33																														33							33			33				33			33			
H8748	003	0	1	02	01	H8748_003_0	8	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H8748	003	0	1	02	01	H8748_003_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H8748	003	0	1	02	01	H8748_003_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H8748	003	0	1	02	01	H8748_003_0	8	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H8748	004	0	1	01	01	H8748_004_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
H8748	004	0	1	01	01	H8748_004_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
H8748	004	0	1	01	01	H8748_004_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
H8748	004	0	1	01	01	H8748_004_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					684.00	33		33																														33							33			33				33			33			
H8748	004	0	1	01	01	H8748_004_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H8822	004	0	1	01	01	H8822_004_0	14	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					8.00		24.00																						8.00		16.00																		8.00					8.00							
H8822	004	0	1	01	01	H8822_004_0	14	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					8.00		24.00																						8.00		16.00																		8.00					8.00							
H8822	004	0	1	01	01	H8822_004_0	14	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		45.00		135.00																						45.00		90.00																		45.00								45.00				
H8822	004	0	1	01	01	H8822_004_0	14	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		80.00		240.00																						80.00		160.00																		80.00								80.00				
H8822	004	0	1	01	01	H8822_004_0	14	5	Specialty Tier	1	4	000010	1	1	110100000010101000000001	30		90							2	30		90							30				31	14					33.00	33		33																					33		33																	33							33			
H8822	004	0	1	01	01	H8822_004_0	14	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					8.00		24.00																						8.00		16.00																		8.00					8.00					1		
H8822	004	0	1	01	01	H8822_004_0	14	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					8.00		24.00																						8.00		16.00																		8.00					8.00					1		
H8870	001	0	1	01	01	H8870_001_0	7	1	Generic	1	4	010000	1	2	011100000010111000000110	31	60	90							1	31	60	90							31		31	14				0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00							
H8870	001	0	1	01	01	H8870_001_0	7	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	31	60	90							1	31	60	90							31				31	14		45.00	90.00	135.00																						45.00	90.00	135.00																		45.00								45.00				
H8870	001	0	1	01	01	H8870_001_0	7	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	31	60	90							1	31	60	90							31				31	14		95.00	190.00	285.00																						95.00	190.00	285.00																		95.00								95.00				
H8870	001	0	1	01	01	H8870_001_0	7	4	Specialty Tier	1	4	010010	1	1	110000000010100000000111	31										31									31		31	14	31	14					389.14	25																							25																			25				25			25			
H8908	001	0	1	01	01	H8908_001_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H8908	001	0	1	01	01	H8908_001_0	5	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H8908	001	0	1	01	01	H8908_001_0	5	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H8908	001	0	1	01	01	H8908_001_0	5	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					901.00	33																														33							33					33				33			33	2	3	
H8908	001	0	1	01	01	H8908_001_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00		2	3	
H8908	001	0	1	01	01	H8908_001_0	5	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H8908	001	0	1	01	01	H8908_001_0	5	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H8908	001	0	1	01	01	H8908_001_0	5	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					785.00	33																														33							33					33				33			33			
H8953	001	0	1	01	01	H8953_001_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H8953	001	0	1	01	01	H8953_001_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H8953	001	0	1	01	01	H8953_001_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					810.00	33																														33							33					33				33			33	2	3	
H8953	001	0	1	01	01	H8953_001_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H8953	001	0	1	01	01	H8953_001_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H8953	001	0	1	01	01	H8953_001_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H8953	001	0	1	01	01	H8953_001_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H8953	001	0	1	01	01	H8953_001_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					694.00	33																														33							33					33				33			33			
H8953	001	0	1	01	01	H8953_001_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H8953	001	0	1	01	01	H8953_001_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H8953	002	0	1	01	01	H8953_002_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					740.00	33																														33							33					33				33			33	2	3	
H8953	002	0	1	01	01	H8953_002_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H8953	002	0	1	01	01	H8953_002_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H8953	002	0	1	01	01	H8953_002_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H8953	002	0	1	01	01	H8953_002_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H8953	002	0	1	01	01	H8953_002_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H8953	002	0	1	01	01	H8953_002_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H8953	002	0	1	01	01	H8953_002_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H8953	002	0	1	01	01	H8953_002_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H8953	002	0	1	01	01	H8953_002_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					661.00	33																														33							33					33				33			33			
H8953	003	0	1	01	01	H8953_003_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H8953	003	0	1	01	01	H8953_003_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					772.00	33																														33							33					33				33			33	2	3	
H8953	003	0	1	01	01	H8953_003_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H8953	003	0	1	01	01	H8953_003_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H8953	003	0	1	01	01	H8953_003_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H8953	003	0	1	01	01	H8953_003_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					681.00	33																														33							33					33				33			33			
H8953	003	0	1	01	01	H8953_003_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H8953	003	0	1	01	01	H8953_003_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H8953	003	0	1	01	01	H8953_003_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H8953	003	0	1	01	01	H8953_003_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H8953	005	0	1	01	01	H8953_005_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H8953	005	0	1	01	01	H8953_005_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H8953	005	0	1	01	01	H8953_005_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H8953	005	0	1	01	01	H8953_005_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H8953	005	0	1	01	01	H8953_005_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					917.00	33																														33							33					33				33			33	2	3	
H8953	005	0	1	01	01	H8953_005_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H8953	005	0	1	01	01	H8953_005_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H8953	005	0	1	01	01	H8953_005_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H8953	005	0	1	01	01	H8953_005_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H8953	005	0	1	01	01	H8953_005_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					798.00	33																														33							33					33				33			33			
H8953	006	0	1	01	01	H8953_006_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H8953	006	0	1	01	01	H8953_006_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H8953	006	0	1	01	01	H8953_006_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H8953	006	0	1	01	01	H8953_006_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H8953	006	0	1	01	01	H8953_006_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					750.00	33																														33							33					33				33			33			
H8953	006	0	1	01	01	H8953_006_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H8953	006	0	1	01	01	H8953_006_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H8953	006	0	1	01	01	H8953_006_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H8953	006	0	1	01	01	H8953_006_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H8953	006	0	1	01	01	H8953_006_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					869.00	33																														33							33					33				33			33	2	3	
H8953	007	0	1	01	01	H8953_007_0	9	1	Preferred Generic	1	2	001010		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H8953	007	0	1	01	01	H8953_007_0	9	2	Non-Preferred Generic	1	2	000101		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H8953	007	0	1	01	01	H8953_007_0	9	3	Preferred Brand	1	2	000101		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		39.00		117.00																													39.00		107.00					39.00		117.00				39.00					39.00			39.00				
H8953	007	0	1	01	01	H8953_007_0	9	4	Non-Preferred Brand	1	2	110000		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		94.00		282.00																													94.00		272.00					94.00		282.00				94.00					94.00			94.00				
H8953	007	0	1	01	01	H8953_007_0	9	5	Specialty Tier	1	2	010010		1	110000000010000100100101	30													30			30			30		31		31	14					485.00	25																														25							25					25				25			25			
H8953	008	0	1	01	01	H8953_008_0	7	1	Preferred Generic	1	2	001010		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H8953	008	0	1	01	01	H8953_008_0	7	2	Preferred Brand	1	2	010001		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		41.00		123.00																													41.00		113.00					41.00		123.00				41.00					41.00			41.00				
H8953	008	0	1	01	01	H8953_008_0	7	3	Non-Preferred Brand	1	2	100100		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
H8953	008	0	1	01	01	H8953_008_0	7	4	Specialty Tier	1	2	010010		1	110000000010000100100101	30													30			30			30		31		31	14					506.00	25																														25							25					25				25			25			
H8953	009	0	1	01	01	H8953_009_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H8953	009	0	1	01	01	H8953_009_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					860.00	33																														33							33					33				33			33	2	3	
H8953	009	0	1	01	01	H8953_009_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H8953	009	0	1	01	01	H8953_009_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H8953	009	0	1	01	01	H8953_009_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H8953	009	0	1	01	01	H8953_009_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H8953	009	0	1	01	01	H8953_009_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					741.00	33																														33							33					33				33			33			
H8953	009	0	1	01	01	H8953_009_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H8953	009	0	1	01	01	H8953_009_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H8953	009	0	1	01	01	H8953_009_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H8953	010	0	1	01	01	H8953_010_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H8953	010	0	1	01	01	H8953_010_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H8953	010	0	1	01	01	H8953_010_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H8953	010	0	1	01	01	H8953_010_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H8953	010	0	1	01	01	H8953_010_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					902.00	33																														33							33					33				33			33	2	3	
H8953	010	0	1	01	01	H8953_010_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H8953	010	0	1	01	01	H8953_010_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H8953	010	0	1	01	01	H8953_010_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H8953	010	0	1	01	01	H8953_010_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H8953	010	0	1	01	01	H8953_010_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					776.00	33																														33							33					33				33			33			
H8953	011	0	1	01	01	H8953_011_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					780.00	33																														33							33					33				33			33			
H8953	011	0	1	01	01	H8953_011_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H8953	011	0	1	01	01	H8953_011_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H8953	011	0	1	01	01	H8953_011_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H8953	011	0	1	01	01	H8953_011_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H8953	011	0	1	01	01	H8953_011_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					927.00	33																														33							33					33				33			33	2	3	
H8953	011	0	1	01	01	H8953_011_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H8953	011	0	1	01	01	H8953_011_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H8953	011	0	1	01	01	H8953_011_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H8953	011	0	1	01	01	H8953_011_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H8953	012	0	1	01	01	H8953_012_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					966.00	33																														33							33					33				33			33	2	3	
H8953	012	0	1	01	01	H8953_012_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
H8953	012	0	1	01	01	H8953_012_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
H8953	012	0	1	01	01	H8953_012_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
H8953	012	0	1	01	01	H8953_012_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
H8953	012	0	1	01	01	H8953_012_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
H8953	012	0	1	01	01	H8953_012_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
H8953	012	0	1	01	01	H8953_012_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
H8953	012	0	1	01	01	H8953_012_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	1
H8953	012	0	1	01	01	H8953_012_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					817.00	33																														33							33					33				33			33			
H8953	014	0	1	01	01	H8953_014_0	6	1	Preferred Generic	1	2	001010		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H8953	014	0	1	01	01	H8953_014_0	6	3	Preferred Brand	1	2	000101		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		38.00		114.00																													38.00		104.00					38.00		114.00				38.00					38.00			38.00				
H8953	014	0	1	01	01	H8953_014_0	6	4	Non-Preferred Brand	1	2	110000		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00				
H8953	014	0	1	01	01	H8953_014_0	6	5	Specialty Tier	1	2	010010		1	110000000010000100100101	30													30			30			30		31		31	14					460.00	25																														25							25					25				25			25			
H8953	014	0	1	01	01	H8953_014_0	6	2	Non-Preferred Generic	1	2	000101		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
H8980	002	0	1	04	01	H8980_002_0	9	4	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		80.00		240.00																						80.00		240.00																		80.00					80.00			80.00				
H8980	002	0	1	04	01	H8980_002_0	9	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					328.35	33																																										33				33			33			
H8980	002	0	1	04	01	H8980_002_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		41.00		123.00																						41.00		102.50																		41.00								41.00				
H8980	002	0	1	04	01	H8980_002_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					25.00		75.00																						25.00		62.50																		25.00					25.00							
H8980	002	0	1	04	01	H8980_002_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					4.00		12.00																						4.00		10.00																		4.00					4.00							
H8980	004	0	1	04	01	H8980_004_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					292.30	33																																										33				33			33			
H8980	004	0	1	04	01	H8980_004_0	7	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					4.00		12.00																						4.00		10.00																		4.00					4.00					1		
H8980	004	0	1	04	01	H8980_004_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					4.00		12.00																						4.00		10.00																		4.00					4.00							
H8980	004	0	1	04	01	H8980_004_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					25.00		75.00																						25.00		62.50																		25.00					25.00							
H8980	004	0	1	04	01	H8980_004_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		41.00		123.00																						41.00		102.50																		41.00								41.00				
H8980	004	0	1	04	01	H8980_004_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		80.00		240.00																						80.00		240.00																		80.00					80.00			80.00				
H8991	017	0	1	01	01	H8991_017_0	7	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	31	62	93							2	31	62	93							31		31	1				0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00					1		
H8991	017	0	1	01	01	H8991_017_0	7	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	31	62	93							2	31	62	93							31		31	1				0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00							
H8991	017	0	1	01	01	H8991_017_0	7	2	Non-Preferred Generic	1	4	000100	1	1	011100000010111000000110	31	62	93							2	31	62	93							31		31	1							7.00	25	25	25																					25	25	25																	25				25						
H8991	017	0	1	01	01	H8991_017_0	7	5	Specialty Tier	1	4	100100	1	1	111100000010111000000111	31	62	93							2	31	62	93							31		31	1	31	1					435.00	25	25	25																					25	25	25																	25				25			25			
H8991	017	0	1	01	01	H8991_017_0	7	4	Non-Preferred Brand	1	4	100000	1	1	111100000010111000000001	31	62	93							2	31	62	93							31				31	1					63.00	25	25	25																					25	25	25																	25							25			
H8991	017	0	1	01	01	H8991_017_0	7	3	Preferred Brand	1	4	000001	1	1	111100000010111000000001	31	62	93							2	31	62	93							31				31	1					41.00	25	25	25																					25	25	25																	25							25			
H8991	028	0	1	01	01	H8991_028_0	7	4	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	31	62	93							2	31	62	93							31				31	1		80.00	160.00	240.00																						80.00	120.00	160.00																		80.00								80.00				
H8991	028	0	1	01	01	H8991_028_0	7	3	Preferred Brand	1	4	000001	1	2	111100000010111000000001	31	62	93							2	31	62	93							31				31	1		35.00	70.00	105.00																						35.00	52.50	70.00																		35.00								35.00				
H8991	028	0	1	01	01	H8991_028_0	7	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	31	62	93							2	31	62	93							31		31	1				4.00	8.00	12.00																						4.00	6.00	8.00																		4.00					4.00							
H8991	028	0	1	01	01	H8991_028_0	7	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	31	62	93							2	31	62	93							31		31	1				2.00	4.00	6.00																						2.00	3.00	4.00																		2.00					2.00							
H8991	028	0	1	01	01	H8991_028_0	7	5	Specialty Tier	1	4	100100	1	1	111100000010111000000111	31	62	93							2	31	62	93							31		31	1	31	1					575.00	33	33	33																					33	33	33																	33				33			33			
H9001	011	0	1	01	01	H9001_011_0	4	1	Preferred Generic	1	4	001000	3	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					4.00	8.00	12.00																						4.00	8.00	12.00																		4.00					4.00							
H9001	011	0	1	01	01	H9001_011_0	4	2	Preferred Brand	1	4	000101	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		32.00	64.00	96.00																						32.00	64.00	96.00																		32.00					32.00			32.00				
H9001	011	0	1	01	01	H9001_011_0	4	4	Specialty Tier	1	4	100100	1	1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					491.03	25	25	25																					25	25	25																	25				25			25			
H9001	011	0	1	01	01	H9001_011_0	4	3	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		76.00	152.00	228.00																						76.00	152.00	228.00																		76.00					76.00			76.00				
H9001	013	0	1	01	01	H9001_013_0	4	2	Preferred Brand	1	4	000101	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		27.00	54.00	81.00																						27.00	54.00	81.00																		27.00					27.00			27.00				
H9001	013	0	1	01	01	H9001_013_0	4	1	Preferred Generic	1	4	001000	3	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					4.00	8.00	12.00																						4.00	8.00	12.00																		4.00					4.00							
H9001	013	0	1	01	01	H9001_013_0	4	3	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		76.00	152.00	228.00																						76.00	152.00	228.00																		76.00					76.00			76.00				
H9001	015	0	1	01	01	H9001_015_0	4	3	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		76.00	152.00	228.00																						76.00	152.00	228.00																		76.00					76.00			76.00				
H9001	015	0	1	01	01	H9001_015_0	4	2	Preferred Brand	1	4	000101	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		27.00	54.00	81.00																						27.00	54.00	81.00																		27.00					27.00			27.00				
H9001	015	0	1	01	01	H9001_015_0	4	1	Preferred Generic	1	4	001000	3	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					4.00	8.00	12.00																						4.00	8.00	12.00																		4.00					4.00							
H9001	017	0	1	01	01	H9001_017_0	4	3	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		76.00	152.00	228.00																						76.00	152.00	228.00																		76.00					76.00			76.00				
H9001	017	0	1	01	01	H9001_017_0	4	2	Preferred Brand	1	4	000101	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		27.00	54.00	81.00																						27.00	54.00	81.00																		27.00					27.00			27.00				
H9001	017	0	1	01	01	H9001_017_0	4	1	Preferred Generic	1	4	001000	3	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					4.00	8.00	12.00																						4.00	8.00	12.00																		4.00					4.00							
H9001	021	0	1	01	01	H9001_021_0	4	3	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		76.00	152.00	228.00																						76.00	152.00	228.00																		76.00					76.00			76.00				
H9001	021	0	1	01	01	H9001_021_0	4	1	Preferred Generic	1	4	001000	3	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					4.00	8.00	12.00																						4.00	8.00	12.00																		4.00					4.00							
H9001	021	0	1	01	01	H9001_021_0	4	2	Preferred Brand	1	4	000101	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		27.00	54.00	81.00																						27.00	54.00	81.00																		27.00					27.00			27.00				
H9001	025	0	1	01	01	H9001_025_0	4	3	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		76.00	152.00	228.00																						76.00	152.00	228.00																		76.00					76.00			76.00				
H9001	025	0	1	01	01	H9001_025_0	4	2	Preferred Brand	1	4	000101	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		27.00	54.00	81.00																						27.00	54.00	81.00																		27.00					27.00			27.00				
H9001	025	0	1	01	01	H9001_025_0	4	1	Preferred Generic	1	4	001000	3	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					4.00	8.00	12.00																						4.00	8.00	12.00																		4.00					4.00							
H9001	027	0	1	01	01	H9001_027_0	4	1	Preferred Generic	1	4	001000	3	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					4.00	8.00	12.00																						4.00	8.00	12.00																		4.00					4.00							
H9001	027	0	1	01	01	H9001_027_0	4	4	Specialty Tier	1	4	100100	1	1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					494.61	25	25	25																					25	25	25																	25				25			25			
H9001	027	0	1	01	01	H9001_027_0	4	3	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		76.00	152.00	228.00																						76.00	152.00	228.00																		76.00					76.00			76.00				
H9001	027	0	1	01	01	H9001_027_0	4	2	Preferred Brand	1	4	000101	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		32.00	64.00	96.00																						32.00	64.00	96.00																		32.00					32.00			32.00				
H9001	028	0	1	01	01	H9001_028_0	4	1	Preferred Generic	1	4	001000	3	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					4.00	8.00	12.00																						4.00	8.00	12.00																		4.00					4.00							
H9001	028	0	1	01	01	H9001_028_0	4	2	Preferred Brand	1	4	000101	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		32.00	64.00	96.00																						32.00	64.00	96.00																		32.00					32.00			32.00				
H9001	028	0	1	01	01	H9001_028_0	4	4	Specialty Tier	1	4	100100	1	1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					495.07	25	25	25																					25	25	25																	25				25			25			
H9001	028	0	1	01	01	H9001_028_0	4	3	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		76.00	152.00	228.00																						76.00	152.00	228.00																		76.00					76.00			76.00				
H9001	030	1	1	01	01	H9001_030_1	4	3	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		76.00	152.00	228.00																						76.00	152.00	228.00																		76.00					76.00			76.00				
H9001	030	1	1	01	01	H9001_030_1	4	2	Preferred Brand	1	4	000101	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		27.00	54.00	81.00																						27.00	54.00	81.00																		27.00					27.00			27.00				
H9001	030	1	1	01	01	H9001_030_1	4	1	Preferred Generic	1	4	001000	3	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					4.00	8.00	12.00																						4.00	8.00	12.00																		4.00					4.00							
H9001	030	2	1	01	01	H9001_030_2	4	2	Preferred Brand	1	4	000101	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		27.00	54.00	81.00																						27.00	54.00	81.00																		27.00					27.00			27.00				
H9001	030	2	1	01	01	H9001_030_2	4	3	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		76.00	152.00	228.00																						76.00	152.00	228.00																		76.00					76.00			76.00				
H9001	030	2	1	01	01	H9001_030_2	4	1	Preferred Generic	1	4	001000	3	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					4.00	8.00	12.00																						4.00	8.00	12.00																		4.00					4.00							
H9001	030	4	1	01	01	H9001_030_4	4	1	Preferred Generic	1	4	001000	3	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					4.00	8.00	12.00																						4.00	8.00	12.00																		4.00					4.00							
H9001	030	4	1	01	01	H9001_030_4	4	3	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		76.00	152.00	228.00																						76.00	152.00	228.00																		76.00					76.00			76.00				
H9001	030	4	1	01	01	H9001_030_4	4	2	Preferred Brand	1	4	000101	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		27.00	54.00	81.00																						27.00	54.00	81.00																		27.00					27.00			27.00				
H9001	030	5	1	01	01	H9001_030_5	4	3	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		76.00	152.00	228.00																						76.00	152.00	228.00																		76.00					76.00			76.00				
H9001	030	5	1	01	01	H9001_030_5	4	2	Preferred Brand	1	4	000101	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		27.00	54.00	81.00																						27.00	54.00	81.00																		27.00					27.00			27.00				
H9001	030	5	1	01	01	H9001_030_5	4	1	Preferred Generic	1	4	001000	3	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					4.00	8.00	12.00																						4.00	8.00	12.00																		4.00					4.00							
H9001	031	1	1	01	01	H9001_031_1	4	2	Preferred Brand	1	4	000101	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		27.00	54.00	81.00																						27.00	54.00	81.00																		27.00					27.00			27.00				
H9001	031	1	1	01	01	H9001_031_1	4	1	Preferred Generic	1	4	001000	3	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					4.00	8.00	12.00																						4.00	8.00	12.00																		4.00					4.00							
H9001	031	1	1	01	01	H9001_031_1	4	3	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		76.00	152.00	228.00																						76.00	152.00	228.00																		76.00					76.00			76.00				
H9001	031	2	1	01	01	H9001_031_2	4	2	Preferred Brand	1	4	000101	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		27.00	54.00	81.00																						27.00	54.00	81.00																		27.00					27.00			27.00				
H9001	031	2	1	01	01	H9001_031_2	4	1	Preferred Generic	1	4	001000	3	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					4.00	8.00	12.00																						4.00	8.00	12.00																		4.00					4.00							
H9001	031	2	1	01	01	H9001_031_2	4	3	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		76.00	152.00	228.00																						76.00	152.00	228.00																		76.00					76.00			76.00				
H9001	031	4	1	01	01	H9001_031_4	4	3	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		76.00	152.00	228.00																						76.00	152.00	228.00																		76.00					76.00			76.00				
H9001	031	4	1	01	01	H9001_031_4	4	1	Preferred Generic	1	4	001000	3	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					4.00	8.00	12.00																						4.00	8.00	12.00																		4.00					4.00							
H9001	031	4	1	01	01	H9001_031_4	4	2	Preferred Brand	1	4	000101	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		27.00	54.00	81.00																						27.00	54.00	81.00																		27.00					27.00			27.00				
H9001	031	5	1	01	01	H9001_031_5	4	2	Preferred Brand	1	4	000101	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		27.00	54.00	81.00																						27.00	54.00	81.00																		27.00					27.00			27.00				
H9001	031	5	1	01	01	H9001_031_5	4	1	Preferred Generic	1	4	001000	3	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					4.00	8.00	12.00																						4.00	8.00	12.00																		4.00					4.00							
H9001	031	5	1	01	01	H9001_031_5	4	3	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		76.00	152.00	228.00																						76.00	152.00	228.00																		76.00					76.00			76.00				
H9001	032	1	1	01	01	H9001_032_1	4	1	Preferred Generic	1	4	001000	3	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					4.00	8.00	12.00																						4.00	8.00	12.00																		4.00					4.00							
H9001	032	1	1	01	01	H9001_032_1	4	2	Preferred Brand	1	4	000101	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		32.00	64.00	96.00																						32.00	64.00	96.00																		32.00					32.00			32.00				
H9001	032	1	1	01	01	H9001_032_1	4	3	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		76.00	152.00	228.00																						76.00	152.00	228.00																		76.00					76.00			76.00				
H9001	032	1	1	01	01	H9001_032_1	4	4	Specialty Tier	1	4	100100	1	1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					498.07	25	25	25																					25	25	25																	25				25			25			
H9001	032	2	1	01	01	H9001_032_2	4	1	Preferred Generic	1	4	001000	3	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					4.00	8.00	12.00																						4.00	8.00	12.00																		4.00					4.00							
H9001	032	2	1	01	01	H9001_032_2	4	2	Preferred Brand	1	4	000101	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		32.00	64.00	96.00																						32.00	64.00	96.00																		32.00					32.00			32.00				
H9001	032	2	1	01	01	H9001_032_2	4	3	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		76.00	152.00	228.00																						76.00	152.00	228.00																		76.00					76.00			76.00				
H9001	032	2	1	01	01	H9001_032_2	4	4	Specialty Tier	1	4	100100	1	1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					498.07	25	25	25																					25	25	25																	25				25			25			
H9001	032	4	1	01	01	H9001_032_4	4	1	Preferred Generic	1	4	001000	3	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					4.00	8.00	12.00																						4.00	8.00	12.00																		4.00					4.00							
H9001	032	4	1	01	01	H9001_032_4	4	2	Preferred Brand	1	4	000101	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		32.00	64.00	96.00																						32.00	64.00	96.00																		32.00					32.00			32.00				
H9001	032	4	1	01	01	H9001_032_4	4	4	Specialty Tier	1	4	100100	1	1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					498.07	25	25	25																					25	25	25																	25				25			25			
H9001	032	4	1	01	01	H9001_032_4	4	3	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		76.00	152.00	228.00																						76.00	152.00	228.00																		76.00					76.00			76.00				
H9001	032	5	1	01	01	H9001_032_5	4	4	Specialty Tier	1	4	100100	1	1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					498.07	25	25	25																					25	25	25																	25				25			25			
H9001	032	5	1	01	01	H9001_032_5	4	2	Preferred Brand	1	4	000101	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		32.00	64.00	96.00																						32.00	64.00	96.00																		32.00					32.00			32.00				
H9001	032	5	1	01	01	H9001_032_5	4	3	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14		76.00	152.00	228.00																						76.00	152.00	228.00																		76.00					76.00			76.00				
H9001	032	5	1	01	01	H9001_032_5	4	1	Preferred Generic	1	4	001000	3	2	011100000010111000000100	30	60	90							2	30	60	90							30		31					4.00	8.00	12.00																						4.00	8.00	12.00																		4.00					4.00							
H9003	001	0	1	01	01	H9003_001_0	8	6	Vaccines	3	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00										1		
H9003	001	0	1	01	01	H9003_001_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					6.00		18.00																						6.00		12.00																		6.00					6.00							
H9003	001	0	1	01	01	H9003_001_0	8	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00					1		
H9003	001	0	1	01	01	H9003_001_0	8	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					6.00		18.00																						6.00		12.00																		6.00					6.00					1		
H9003	001	0	1	01	01	H9003_001_0	8	6	Vaccines	1	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00												
H9003	001	0	1	01	01	H9003_001_0	8	5	Specialty Tier	1	4	100001	1	1	110100000010101000000001	30		90							2	30		90							30				31	10					417.00	25		25																					25		25																	25							25			
H9003	001	0	1	01	01	H9003_001_0	8	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							2	30		90							30				31	10		65.00		195.00																						65.00		130.00																		65.00								65.00				
H9003	001	0	1	01	01	H9003_001_0	8	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	10		45.00		135.00																						45.00		90.00																		45.00								45.00				
H9003	001	0	1	01	01	H9003_001_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00							
H9003	006	0	1	01	01	H9003_006_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					6.00		18.00																						6.00		12.00																		6.00					6.00							
H9003	006	0	1	01	01	H9003_006_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00							
H9003	006	0	1	01	01	H9003_006_0	8	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	10		45.00		135.00																						45.00		90.00																		45.00								45.00				
H9003	006	0	1	01	01	H9003_006_0	8	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							2	30		90							30				31	10		65.00		195.00																						65.00		130.00																		65.00								65.00				
H9003	006	0	1	01	01	H9003_006_0	8	5	Specialty Tier	1	4	100001	1	1	110100000010101000000001	30		90							2	30		90							30				31	10					606.00	25		25																					25		25																	25							25			
H9003	006	0	1	01	01	H9003_006_0	8	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00					1		
H9003	006	0	1	01	01	H9003_006_0	8	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					6.00		18.00																						6.00		12.00																		6.00					6.00					1		
H9003	006	0	1	01	01	H9003_006_0	8	6	Vaccines	1	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00												
H9003	006	0	1	01	01	H9003_006_0	8	6	Vaccines	3	4	000001	1	2	110000000010000000000000	30																			30					1		0.00																																												0.00										1		
H9011	003	0	1	01	01	H9011_003_0	7	2	Non-Preferred Generic	3	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00					1		
H9011	003	0	1	01	01	H9011_003_0	7	1	Preferred Generic	3	4	001000	3	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00					1		
H9011	003	0	1	01	01	H9011_003_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					576.00	33		33																														33							33			33				33			33			
H9011	003	0	1	01	01	H9011_003_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		30.00		90.00																															80.00							90.00				30.00					30.00			30.00				
H9011	003	0	1	01	01	H9011_003_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		0.00		0.00																															0.00							0.00				0.00					0.00			0.00				
H9011	003	0	1	01	01	H9011_003_0	7	1	Preferred Generic	1	4	001000	3	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00							
H9011	003	0	1	01	01	H9011_003_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00							
H9011	016	0	1	02	01	H9011_016_0	7	1	Preferred Generic	1	4	001000	3	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00							
H9011	016	0	1	02	01	H9011_016_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00							
H9011	016	0	1	02	01	H9011_016_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		0.00		0.00																															0.00							0.00				0.00					0.00			0.00				
H9011	016	0	1	02	01	H9011_016_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		30.00		90.00																															80.00							90.00				30.00					30.00			30.00				
H9011	016	0	1	02	01	H9011_016_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					422.00	33		33																														33							33			33				33			33			
H9011	018	0	1	01	01	H9011_018_0	8	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		30.00		90.00																															80.00							90.00				30.00					30.00			30.00				
H9011	018	0	1	01	01	H9011_018_0	8	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		89.00		267.00																															257.00							267.00				89.00					89.00			89.00				
H9011	018	0	1	01	01	H9011_018_0	8	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					377.00	33		33																														33							33			33				33			33			
H9011	018	0	1	01	01	H9011_018_0	8	1	Preferred Generic	3	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00					1		
H9011	018	0	1	01	01	H9011_018_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00							
H9011	018	0	1	01	01	H9011_018_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00							
H9011	018	0	1	01	01	H9011_018_0	8	2	Non-Preferred Generic	3	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00					1		
H9011	019	0	1	02	01	H9011_019_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00							
H9011	019	0	1	02	01	H9011_019_0	8	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		30.00		90.00																															80.00							90.00				30.00					30.00			30.00				
H9011	019	0	1	02	01	H9011_019_0	8	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		89.00		267.00																															257.00							267.00				89.00					89.00			89.00				
H9011	019	0	1	02	01	H9011_019_0	8	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					603.00	33		33																														33							33			33				33			33			
H9011	019	0	1	02	01	H9011_019_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00							
H9011	020	0	1	01	01	H9011_020_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					405.00	33		33																														33							33			33				33			33			
H9011	020	0	1	01	01	H9011_020_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H9011	020	0	1	01	01	H9011_020_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		89.00		267.00																															257.00							267.00				89.00					89.00			89.00				
H9011	020	0	1	01	01	H9011_020_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00							
H9011	020	0	1	01	01	H9011_020_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00							
H9011	021	0	1	02	01	H9011_021_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					2.00		6.00																															0.00							6.00				2.00					2.00							
H9011	021	0	1	02	01	H9011_021_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					5.00		15.00																															0.00							15.00				5.00					5.00							
H9011	021	0	1	02	01	H9011_021_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
H9011	021	0	1	02	01	H9011_021_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		92.00		276.00																															266.00							276.00				92.00					92.00			92.00				
H9011	021	0	1	02	01	H9011_021_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					502.00	33		33																														33							33			33				33			33			
H9047	001	0	1	01	01	H9047_001_0	17	2	Non-Preferred Generic	1	4	000100	1	2	000011111110000111111110				30	60	90	30	60	90	1				30	60	90	30	60	90	30		34	14												11.00	22.00	33.00						15.00	30.00	45.00													11.00	22.00	33.00					15.00	30.00	45.00				15.00					15.00							
H9047	001	0	1	01	01	H9047_001_0	17	1	Preferred Generic	1	4	001000	1	2	000011111110000111111110				30	60	90	30	60	90	1				30	60	90	30	60	90	30		34	14												6.00	12.00	18.00						9.00	18.00	27.00													6.00	12.00	18.00					9.00	18.00	27.00				9.00					9.00							
H9047	001	0	1	01	01	H9047_001_0	17	3	Preferred Brand	1	4	000001	1	2	100011111110000111111001				30	60	90	30	60	90	1				30	60	90	30	60	90	30				34	14										35.00	70.00	105.00						35.00	70.00	105.00													35.00	70.00	105.00					35.00	70.00	105.00				35.00								35.00				
H9047	001	0	1	01	01	H9047_001_0	17	4	Non-Preferred Brand	1	4	100000	1	2	100011111110000111111001				30	60	90	30	60	90	1				30	60	90	30	60	90	30				34	14										70.00	140.00	210.00						70.00	140.00	210.00													70.00	140.00	210.00					70.00	140.00	210.00				70.00								70.00				
H9047	001	0	1	01	01	H9047_001_0	17	5	Injectable Drugs	1	4	010010	1	1	100010010010000100100111				30			30							30			30			30		34	14	34	14													48.38	33							48.38	33														33							33					33				33			33			
H9047	001	0	1	01	01	H9047_001_0	17	6	Specialty Tier	1	4	010010	1	1	100010010010000100100111				30			30							30			30			30		34	14	34	14													150.35	33							150.35	33														33							33					33				33			33			
H9047	013	0	2	01	01	H9047_013_0	16	2	Non-Preferred Generic	1	4	000100	1	2	000011111110000111111110				30	60	90	30	60	90	1				30	60	90	30	60	90	30		34	14												11.00	22.00	33.00						15.00	30.00	45.00													11.00	22.00	33.00					15.00	30.00	45.00				15.00					15.00							
H9047	013	0	2	01	01	H9047_013_0	16	1	Preferred Generic	1	4	001000	1	2	000011111110000111111110				30	60	90	30	60	90	1				30	60	90	30	60	90	30		34	14												6.00	12.00	18.00						9.00	18.00	27.00													6.00	12.00	18.00					9.00	18.00	27.00				9.00					9.00							
H9047	013	0	2	01	01	H9047_013_0	16	3	Preferred Brand	1	4	000001	1	2	100011111110000111111001				30	60	90	30	60	90	1				30	60	90	30	60	90	30				34	14										35.00	70.00	105.00						35.00	70.00	105.00													35.00	70.00	105.00					35.00	70.00	105.00				35.00								35.00				
H9047	013	0	2	01	01	H9047_013_0	16	6	Specialty Tier	1	4	010010	1	1	100010010010000100100111				30			30							30			30			30		34	14	34	14													150.35	33							150.35	33														33							33					33				33			33			
H9047	013	0	2	01	01	H9047_013_0	16	5	Injectable Drugs	1	4	010010	1	1	100010010010000100100111				30			30							30			30			30		34	14	34	14													48.38	33							48.38	33														33							33					33				33			33			
H9047	013	0	2	01	01	H9047_013_0	16	4	Non-Preferred Brand	1	4	100000	1	2	100011111110000111111001				30	60	90	30	60	90	1				30	60	90	30	60	90	30				34	14										70.00	140.00	210.00						70.00	140.00	210.00													70.00	140.00	210.00					70.00	140.00	210.00				70.00								70.00				
H9047	024	0	1	02	01	H9047_024_0	17	1	Preferred Generic	1	4	001000	1	2	000011111110000111111110				30	60	90	30	60	90	1				30	60	90	30	60	90	30		34	14												6.00	12.00	18.00						9.00	18.00	27.00													6.00	12.00	18.00					9.00	18.00	27.00				9.00					9.00							
H9047	024	0	1	02	01	H9047_024_0	17	2	Non-Preferred Generic	1	4	000100	1	2	000011111110000111111110				30	60	90	30	60	90	1				30	60	90	30	60	90	30		34	14												11.00	22.00	33.00						15.00	30.00	45.00													11.00	22.00	33.00					15.00	30.00	45.00				15.00					15.00							
H9047	024	0	1	02	01	H9047_024_0	17	5	Injectable Drugs	1	4	010010	1	1	100010010010000100100111				30			30							30			30			30		34	14	34	14													48.38	33							48.38	33														33							33					33				33			33			
H9047	024	0	1	02	01	H9047_024_0	17	4	Non-Preferred Brand	1	4	100000	1	2	100011111110000111111001				30	60	90	30	60	90	1				30	60	90	30	60	90	30				34	14										70.00	140.00	210.00						70.00	140.00	210.00													70.00	140.00	210.00					70.00	140.00	210.00				70.00								70.00				
H9047	024	0	1	02	01	H9047_024_0	17	3	Preferred Brand	1	4	000001	1	2	100011111110000111111001				30	60	90	30	60	90	1				30	60	90	30	60	90	30				34	14										35.00	70.00	105.00						35.00	70.00	105.00													35.00	70.00	105.00					35.00	70.00	105.00				35.00								35.00				
H9047	024	0	1	02	01	H9047_024_0	17	6	Specialty Tier	1	4	010010	1	1	100010010010000100100111				30			30							30			30			30		34	14	34	14													150.35	33							150.35	33														33							33					33				33			33			
H9082	002	0	1	01	01	H9082_002_0	6	1	Generic	1	4	010000	1	2	011100000010111000000110	31	60	90							1	31	60	90							31		31	14				5.00	10.00	15.00																						5.00	10.00	15.00																		5.00					5.00							
H9082	002	0	1	01	01	H9082_002_0	6	4	Specialty Tier	1	4	010010	1	1	110000000010100000000111	31										31									31		31	14	31	14					527.87	33																							33																			33				33			33			
H9082	002	0	1	01	01	H9082_002_0	6	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	31	60	90							1	31	60	90							31				31	14		60.00	120.00	180.00																						60.00	120.00	180.00																		60.00								60.00				
H9082	002	0	1	01	01	H9082_002_0	6	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	31	60	90							1	31	60	90							31				31	14		30.00	60.00	90.00																						30.00	60.00	90.00																		30.00								30.00				
H9104	006	0	1	01	01	H9104_006_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				3.00		9.00																								6.00																		3.00					3.00							
H9104	006	0	1	01	01	H9104_006_0	8	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	31		90							1			90							31		31	14				8.00		24.00																								16.00																		8.00					8.00					1		
H9104	006	0	1	01	01	H9104_006_0	8	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	31		90							1			90							31				31	14		39.00		117.00																								78.00																		39.00								39.00				
H9104	006	0	1	01	01	H9104_006_0	8	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	31		90							1			90							31				31	14		80.00		240.00																								160.00																		80.00								80.00				
H9104	006	0	1	01	01	H9104_006_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	31		90							1			90							31		31	14				8.00		24.00																								16.00																		8.00					8.00							
H9104	006	0	1	01	01	H9104_006_0	8	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				3.00		9.00																								6.00																		3.00					3.00					1		
H9104	006	0	1	01	01	H9104_006_0	8	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	31		90							1			90							31				31	14		10.00		30.00																								20.00																		10.00								10.00				
H9104	006	0	1	01	01	H9104_006_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010000000000111	31																			31		31	14	31	14					430.89	33																																										33				33			33			
H9104	007	0	1	01	01	H9104_007_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010000000000111	31																			31		31	14	31	14					430.89	33																																										33				33			33			
H9104	007	0	1	01	01	H9104_007_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				3.00		9.00																								6.00																		3.00					3.00							
H9104	007	0	1	01	01	H9104_007_0	8	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				3.00		9.00																								6.00																		3.00					3.00					1		
H9104	007	0	1	01	01	H9104_007_0	8	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	31		90							1			90							31		31	14				8.00		24.00																								16.00																		8.00					8.00					1		
H9104	007	0	1	01	01	H9104_007_0	8	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	31		90							1			90							31				31	14		10.00		30.00																								20.00																		10.00								10.00				
H9104	007	0	1	01	01	H9104_007_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	31		90							1			90							31		31	14				8.00		24.00																								16.00																		8.00					8.00							
H9104	007	0	1	01	01	H9104_007_0	8	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	31		90							1			90							31				31	14		39.00		117.00																								78.00																		39.00								39.00				
H9104	007	0	1	01	01	H9104_007_0	8	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	31		90							1			90							31				31	14		80.00		240.00																								160.00																		80.00								80.00				
H9104	008	0	1	01	01	H9104_008_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010000000000111	31																			31		31	14	31	14					430.89	33																																										33				33			33			
H9104	008	0	1	01	01	H9104_008_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				3.00		9.00																								6.00																		3.00					3.00							
H9104	008	0	1	01	01	H9104_008_0	8	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				3.00		9.00																								6.00																		3.00					3.00					1		
H9104	008	0	1	01	01	H9104_008_0	8	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	31		90							1			90							31		31	14				8.00		24.00																								16.00																		8.00					8.00					1		
H9104	008	0	1	01	01	H9104_008_0	8	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	31		90							1			90							31				31	14		10.00		30.00																								20.00																		10.00								10.00				
H9104	008	0	1	01	01	H9104_008_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	31		90							1			90							31		31	14				8.00		24.00																								16.00																		8.00					8.00							
H9104	008	0	1	01	01	H9104_008_0	8	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	31		90							1			90							31				31	14		39.00		117.00																								78.00																		39.00								39.00				
H9104	008	0	1	01	01	H9104_008_0	8	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	31		90							1			90							31				31	14		80.00		240.00																								160.00																		80.00								80.00				
H9104	009	0	1	01	01	H9104_009_0	8	5	Specialty Tier	1	4	010010	1	1	110000000010000000000111	31																			31		31	14	31	14					430.89	33																																										33				33			33			
H9104	009	0	1	01	01	H9104_009_0	8	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	31		90							1			90							31				31	14		10.00		30.00																								20.00																		10.00								10.00				
H9104	009	0	1	01	01	H9104_009_0	8	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				3.00		9.00																								6.00																		3.00					3.00					1		
H9104	009	0	1	01	01	H9104_009_0	8	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	31		90							1			90							31		31	14				8.00		24.00																								16.00																		8.00					8.00					1		
H9104	009	0	1	01	01	H9104_009_0	8	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	31		90							1			90							31				31	14		80.00		240.00																								160.00																		80.00								80.00				
H9104	009	0	1	01	01	H9104_009_0	8	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	31		90							1			90							31				31	14		39.00		117.00																								78.00																		39.00								39.00				
H9104	009	0	1	01	01	H9104_009_0	8	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	31		90							1			90							31		31	14				8.00		24.00																								16.00																		8.00					8.00							
H9104	009	0	1	01	01	H9104_009_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				3.00		9.00																								6.00																		3.00					3.00							
H9285	001	0	1	01	01	H9285_001_0	8	4	Specialty Tier	1	4	100100	1	1	110100000010101000000111	30		90							1	30		90							30		31	14	31	14					1001.96	33		33																					33		33																	33				33			33			
H9285	001	0	1	01	01	H9285_001_0	8	3	Non-Preferred Brand	1	4	100100	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		79.00		237.00																						79.00		158.00																		79.00					79.00			79.00				
H9285	001	0	1	01	01	H9285_001_0	8	2	Preferred Brand	1	4	000101	1	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		39.00		117.00																						39.00		78.00																		39.00					39.00			39.00				
H9285	001	0	1	01	01	H9285_001_0	8	1	Preferred Generic	1	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00				
H9285	002	0	1	01	01	H9285_002_0	8	4	Specialty Tier	1	4	100100	1	1	110100000010101000000111	30		90							1	30		90							30		31	14	31	14					561.52	33		33																					33		33																	33				33			33			
H9285	002	0	1	01	01	H9285_002_0	8	3	Non-Preferred Brand	1	4	100100	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		69.00		207.00																						69.00		138.00																		69.00					69.00			69.00				
H9285	002	0	1	01	01	H9285_002_0	8	2	Preferred Brand	1	4	000101	1	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		20.00		60.00																						20.00		40.00																		20.00					20.00			20.00				
H9285	002	0	1	01	01	H9285_002_0	8	1	Preferred Generic	1	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00				
H9285	002	0	1	01	01	H9285_002_0	8	1	Preferred Generic	3	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00		1		
H9285	003	0	1	01	01	H9285_003_0	8	1	Preferred Generic	1	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00				
H9285	003	0	1	01	01	H9285_003_0	8	2	Preferred Brand	1	4	000101	1	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		20.00		60.00																						20.00		40.00																		20.00					20.00			20.00				
H9285	003	0	1	01	01	H9285_003_0	8	3	Non-Preferred Brand	1	4	100100	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		69.00		207.00																						69.00		138.00																		69.00					69.00			69.00				
H9285	003	0	1	01	01	H9285_003_0	8	4	Specialty Tier	1	4	100100	1	1	110100000010101000000111	30		90							1	30		90							30		31	14	31	14					668.18	33		33																					33		33																	33				33			33			
H9285	004	0	1	01	01	H9285_004_0	8	1	Preferred Generic	1	4	001010	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00				
H9285	004	0	1	01	01	H9285_004_0	8	2	Preferred Brand	1	4	000101	1	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		20.00		60.00																						20.00		40.00																		20.00					20.00			20.00				
H9285	004	0	1	01	01	H9285_004_0	8	3	Non-Preferred Brand	1	4	100100	3	2	110100000010101000000111	30		90							1	30		90							30		31	14	31	14		69.00		207.00																						69.00		138.00																		69.00					69.00			69.00				
H9285	004	0	1	01	01	H9285_004_0	8	4	Specialty Tier	1	4	100100	1	1	110100000010101000000111	30		90							1	30		90							30		31	14	31	14					660.75	33		33																					33		33																	33				33			33			
H9302	001	0	1	01	01	H9302_001_0	11	2	Non-Preferred Generic	3	4	100100	1	2	111100000010111000000111	30	60	90							2	30	60	90							30		31	14	31	14		18.00	36.00	45.00																						18.00	36.00	36.00																		18.00					18.00			18.00		1		
H9302	001	0	1	01	01	H9302_001_0	11	1	Preferred Generic	3	4	001001	1	2	111100000010111000000111	30	60	90							2	30	60	90							30		31	14	31	14		6.00	12.00	15.00																						6.00	12.00	12.00																		6.00					6.00			6.00		1		
H9302	001	0	1	01	01	H9302_001_0	11	5	Specialty Tier	1	4	100100	1	1	111100000010111000000111	30	60	90							2	30	60	90							30		31	14	31	14					627.27	33	33	33																					33	33	33																	33				33			33			
H9302	001	0	1	01	01	H9302_001_0	11	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							2	30	60	90							30		31	14	31	14		60.00	120.00	150.00																						60.00	120.00	120.00																		60.00					60.00			60.00				
H9302	001	0	1	01	01	H9302_001_0	11	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							2	30	60	90							30		31	14	31	14		36.00	72.00	90.00																						36.00	72.00	72.00																		36.00					36.00			36.00				
H9302	001	0	1	01	01	H9302_001_0	11	1	Preferred Generic	1	4	001001	1	2	111100000010111000000111	30	60	90							2	30	60	90							30		31	14	31	14		6.00	12.00	15.00																						6.00	12.00	12.00																		6.00					6.00			6.00				
H9302	001	0	1	01	01	H9302_001_0	11	2	Non-Preferred Generic	1	4	100100	1	2	111100000010111000000111	30	60	90							2	30	60	90							30		31	14	31	14		18.00	36.00	45.00																						18.00	36.00	36.00																		18.00					18.00			18.00				
H9302	003	0	1	01	01	H9302_003_0	11	5	Specialty Tier	1	4	100100	1	1	111100000010111000000111	30	60	90							2	30	60	90							30		31	14	31	14					414.88	33	33	33																					33	33	33																	33				33			33			
H9302	003	0	1	01	01	H9302_003_0	11	1	Preferred Generic	3	4	001001	1	2	111100000010111000000111	30	60	90							2	30	60	90							30		31	14	31	14		6.00	12.00	15.00																						6.00	12.00	12.00																		6.00					6.00			6.00		1		
H9302	003	0	1	01	01	H9302_003_0	11	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							2	30	60	90							30		31	14	31	14		60.00	120.00	150.00																						60.00	120.00	120.00																		60.00					60.00			60.00				
H9302	003	0	1	01	01	H9302_003_0	11	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							2	30	60	90							30		31	14	31	14		36.00	72.00	90.00																						36.00	72.00	72.00																		36.00					36.00			36.00				
H9302	003	0	1	01	01	H9302_003_0	11	2	Non-Preferred Generic	1	4	100100	1	2	111100000010111000000111	30	60	90							2	30	60	90							30		31	14	31	14		18.00	36.00	45.00																						18.00	36.00	36.00																		18.00					18.00			18.00				
H9302	003	0	1	01	01	H9302_003_0	11	1	Preferred Generic	1	4	001001	1	2	111100000010111000000111	30	60	90							2	30	60	90							30		31	14	31	14		6.00	12.00	15.00																						6.00	12.00	12.00																		6.00					6.00			6.00				
H9302	007	0	1	01	01	H9302_007_0	11	1	Preferred Generic	1	4	001001	1	2	111100000010111000000111	30	60	90							2	30	60	90							30		31	14	31	14		6.00	12.00	15.00																						6.00	12.00	12.00																		6.00					6.00			6.00				
H9302	007	0	1	01	01	H9302_007_0	11	2	Non-Preferred Generic	1	4	100100	1	2	111100000010111000000111	30	60	90							2	30	60	90							30		31	14	31	14		18.00	36.00	45.00																						18.00	36.00	36.00																		18.00					18.00			18.00				
H9302	007	0	1	01	01	H9302_007_0	11	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							2	30	60	90							30		31	14	31	14		36.00	72.00	90.00																						36.00	72.00	72.00																		36.00					36.00			36.00				
H9302	007	0	1	01	01	H9302_007_0	11	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							2	30	60	90							30		31	14	31	14		60.00	120.00	150.00																						60.00	120.00	120.00																		60.00					60.00			60.00				
H9302	007	0	1	01	01	H9302_007_0	11	5	Specialty Tier	1	4	100100	1	1	111100000010111000000111	30	60	90							2	30	60	90							30		31	14	31	14					417.98	25	25	25																					25	25	25																	25				25			25			
H9302	010	0	1	01	01	H9302_010_0	11	1	Preferred Generic	1	4	001001	1	2	111100000010111000000111	30	60	90							2	30	60	90							30		31	14	31	14		6.00	12.00	15.00																						6.00	12.00	12.00																		6.00					6.00			6.00				
H9302	010	0	1	01	01	H9302_010_0	11	2	Non-Preferred Generic	1	4	100100	1	2	111100000010111000000111	30	60	90							2	30	60	90							30		31	14	31	14		18.00	36.00	45.00																						18.00	36.00	36.00																		18.00					18.00			18.00				
H9302	010	0	1	01	01	H9302_010_0	11	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							2	30	60	90							30		31	14	31	14		36.00	72.00	90.00																						36.00	72.00	72.00																		36.00					36.00			36.00				
H9302	010	0	1	01	01	H9302_010_0	11	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							2	30	60	90							30		31	14	31	14		60.00	120.00	150.00																						60.00	120.00	120.00																		60.00					60.00			60.00				
H9302	010	0	1	01	01	H9302_010_0	11	5	Specialty Tier	1	4	100100	1	1	111100000010111000000111	30	60	90							2	30	60	90							30		31	14	31	14					417.99	25	25	25																					25	25	25																	25				25			25			
H9385	002	0	1	01	01	H9385_002_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	31		90							1			90							31		31	14				3.00		9.00																								6.00																		3.00					3.00							
H9385	002	0	1	01	01	H9385_002_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	31		90							1			90							31		31	14				10.00		30.00																								20.00																		10.00					10.00							
H9385	002	0	1	01	01	H9385_002_0	7	6	Select Care Drugs	1	4	000010	1	2	110100000010001000000001	31		90							1			90							31				31	14		10.00		30.00																								20.00																		10.00								10.00				
H9385	002	0	1	01	01	H9385_002_0	7	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	31		90							1			90							31				31	14		75.00		225.00																								150.00																		75.00								75.00				
H9385	002	0	1	01	01	H9385_002_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000000000111	31																			31		31	14	31	14					444.38	33																																										33				33			33			
H9385	002	0	1	01	01	H9385_002_0	7	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	31		90							1			90							31				31	14		45.00		135.00																								90.00																		45.00								45.00				
H9412	001	0	1	04	01	H9412_001_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	34		90							2			90							34		34					3.00		9.00																								9.00																		3.00					3.00							
H9412	001	0	1	04	01	H9412_001_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	34		90							2			90							34		34					7.00		21.00																								21.00																		7.00					7.00							
H9412	001	0	1	04	01	H9412_001_0	6	3	Preferred Brand	1	4	010001	1	2	110100000010001000000101	34		90							2			90							34		34		34	14		39.00		117.00																								117.00																		39.00					39.00			39.00				
H9412	001	0	1	04	01	H9412_001_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010001000000101	34		90							2			90							34		34		34	14		69.00		207.00																								207.00																		69.00					69.00			69.00				
H9412	001	0	1	04	01	H9412_001_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	34																			34		34		34	14					734.87	33																																										33				33			33			
H9412	001	0	1	04	01	H9412_001_0	6	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	34		90							2			90							34		34					3.00		9.00																								9.00																		3.00					3.00					1		
H9412	003	0	1	04	01	H9412_003_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	34		90							2			90							34		34					3.00		9.00																								9.00																		3.00					3.00							
H9412	003	0	1	04	01	H9412_003_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	34		90							2			90							34		34					7.00		21.00																								21.00																		7.00					7.00							
H9412	003	0	1	04	01	H9412_003_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010001000000101	34		90							2			90							34		34		34	14		39.00		117.00																								117.00																		39.00					39.00			39.00				
H9412	003	0	1	04	01	H9412_003_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010001000000101	34		90							2			90							34		34		34	14		69.00		207.00																								207.00																		69.00					69.00			69.00				
H9412	003	0	1	04	01	H9412_003_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	34																			34		34		34	14					734.87	33																																										33				33			33			
H9412	003	0	1	04	01	H9412_003_0	7	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	34		90							2			90							34		34					3.00		9.00																								9.00																		3.00					3.00					1		
H9503	001	0	1	04	01	H9503_001_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00		2	3	1
H9503	001	0	1	04	01	H9503_001_0	5	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					845.00	33																														33							33					33				33			33			
H9503	001	0	1	04	01	H9503_001_0	5	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					971.00	33																														33							33					33				33			33	2	3	
H9503	001	0	1	04	01	H9503_001_0	5	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H9503	001	0	1	04	01	H9503_001_0	5	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		42.00		126.00																													42.00		116.00					42.00		126.00				42.00					42.00			42.00		2	2	
H9503	001	0	1	04	01	H9503_001_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H9503	001	0	1	04	01	H9503_001_0	5	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		42.00		126.00																													42.00		116.00					42.00		126.00				42.00					42.00			42.00				
H9503	001	0	1	04	01	H9503_001_0	5	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H9503	003	0	1	04	01	H9503_003_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
H9503	003	0	1	04	01	H9503_003_0	5	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		39.00		117.00																													39.00		107.00					39.00		117.00				39.00					39.00			39.00		2	2	
H9503	003	0	1	04	01	H9503_003_0	5	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H9503	003	0	1	04	01	H9503_003_0	5	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					687.00	33																														33							33					33				33			33	2	3	
H9503	003	0	1	04	01	H9503_003_0	5	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		39.00		117.00																													39.00		107.00					39.00		117.00				39.00					39.00			39.00				
H9503	003	0	1	04	01	H9503_003_0	5	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H9503	003	0	1	04	01	H9503_003_0	5	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					628.00	33																														33							33					33				33			33			
H9503	003	0	1	04	01	H9503_003_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
H9503	006	0	1	04	01	H9503_006_0	6	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
H9503	006	0	1	04	01	H9503_006_0	6	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					920.00	33																														33							33					33				33			33	2	3	
H9503	006	0	1	04	01	H9503_006_0	6	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
H9503	006	0	1	04	01	H9503_006_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00		2	3	1
H9503	006	0	1	04	01	H9503_006_0	6	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					819.00	33																														33							33					33				33			33			
H9503	006	0	1	04	01	H9503_006_0	6	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
H9503	006	0	1	04	01	H9503_006_0	6	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
H9503	006	0	1	04	01	H9503_006_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
H9525	001	0	1	01	01	H9525_001_0	10	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					865.00	33																							33																			33				33			33			
H9525	001	0	1	01	01	H9525_001_0	10	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				4.00	8.00	12.00																						4.00	8.00	6.00																		4.00					4.00							
H9525	001	0	1	01	01	H9525_001_0	10	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				10.00	20.00	30.00																						10.00	20.00	15.00																		10.00					10.00							
H9525	001	0	1	01	01	H9525_001_0	10	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00					45.00			45.00				
H9525	001	0	1	01	01	H9525_001_0	10	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		90.00	180.00	270.00																						90.00	180.00	225.00																		90.00					90.00			90.00				
H9525	001	0	1	01	01	H9525_001_0	10	5	Injectable Drugs	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					62.00	33	33	33																					33	33	33																	33				33			33			
H9525	002	0	1	01	01	H9525_002_0	10	5	Injectable Drugs	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					62.00	33	33	33																					33	33	33																	33				33			33			
H9525	002	0	1	01	01	H9525_002_0	10	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					865.00	33																							33																			33				33			33			
H9525	002	0	1	01	01	H9525_002_0	10	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				4.00	8.00	12.00																						4.00	8.00	6.00																		4.00					4.00							
H9525	002	0	1	01	01	H9525_002_0	10	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		90.00	180.00	270.00																						90.00	180.00	225.00																		90.00					90.00			90.00				
H9525	002	0	1	01	01	H9525_002_0	10	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00					45.00			45.00				
H9525	002	0	1	01	01	H9525_002_0	10	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				10.00	20.00	30.00																						10.00	20.00	15.00																		10.00					10.00							
H9572	001	1	1	04	01	H9572_001_1	10	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				31		90	31		90	1	31		90							31		31													3.00		7.50						3.00		9.00						3.00		7.50																		3.00					3.00							
H9572	001	1	1	04	01	H9572_001_1	10	3	Preferred Brand	1	4	000001	1	2	100010110110101000000001				31		90	31		90	1	31		90							31				31	14										45.00		112.50						45.00		135.00						45.00		112.50																		45.00							1.45	45.00				
H9572	001	1	1	04	01	H9572_001_1	10	4	Non-Preferred Brand	1	4	100000	1	2	100010110110101000000001				31		90	31		90	1	31		90							31				31	14										95.00		237.50						95.00		285.00						95.00		237.50																		95.00							3.06	95.00				
H9572	001	1	1	04	01	H9572_001_1	10	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				31			31				31									31		31		31	14													490.00	30							490.00	30							30																			30				30			30			
H9572	001	1	1	04	01	H9572_001_1	10	2	Non-Preferred Generic	1	4	000100	1	2	000010110110101000000100				31		90	31		90	1	31		90							31		31													15.00		37.50						15.00		45.00						15.00		37.50																		15.00					15.00							
H9572	001	2	1	04	01	H9572_001_2	10	2	Non-Preferred Generic	1	4	000100	1	2	000010110110101000000100				31		90	31		90	1	31		90							31		31													15.00		37.50						15.00		45.00						15.00		37.50																		15.00					15.00							
H9572	001	2	1	04	01	H9572_001_2	10	4	Non-Preferred Brand	1	4	100000	1	2	100010110110101000000001				31		90	31		90	1	31		90							31				31	14										95.00		237.50						95.00		285.00						95.00		237.50																		95.00							3.06	95.00				
H9572	001	2	1	04	01	H9572_001_2	10	3	Preferred Brand	1	4	000001	1	2	100010110110101000000001				31		90	31		90	1	31		90							31				31	14										45.00		112.50						45.00		135.00						45.00		112.50																		45.00							1.45	45.00				
H9572	001	2	1	04	01	H9572_001_2	10	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				31		90	31		90	1	31		90							31		31													3.00		7.50						3.00		9.00						3.00		7.50																		3.00					3.00							
H9572	001	2	1	04	01	H9572_001_2	10	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				31			31				31									31		31		31	14													490.00	30							490.00	30							30																			30				30			30			
H9572	001	3	1	04	01	H9572_001_3	10	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				31			31				31									31		31		31	14													490.00	30							490.00	30							30																			30				30			30			
H9572	001	3	1	04	01	H9572_001_3	10	4	Non-Preferred Brand	1	4	100000	1	2	100010110110101000000001				31		90	31		90	1	31		90							31				31	14										95.00		237.50						95.00		285.00						95.00		237.50																		95.00							3.06	95.00				
H9572	001	3	1	04	01	H9572_001_3	10	3	Preferred Brand	1	4	000001	1	2	100010110110101000000001				31		90	31		90	1	31		90							31				31	14										45.00		112.50						45.00		135.00						45.00		112.50																		45.00							1.45	45.00				
H9572	001	3	1	04	01	H9572_001_3	10	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				31		90	31		90	1	31		90							31		31													3.00		7.50						3.00		9.00						3.00		7.50																		3.00					3.00							
H9572	001	3	1	04	01	H9572_001_3	10	2	Non-Preferred Generic	1	4	000100	1	2	000010110110101000000100				31		90	31		90	1	31		90							31		31													15.00		37.50						15.00		45.00						15.00		37.50																		15.00					15.00							
H9572	001	4	1	04	01	H9572_001_4	10	2	Non-Preferred Generic	1	4	000100	1	2	000010110110101000000100				31		90	31		90	1	31		90							31		31													15.00		37.50						15.00		45.00						15.00		37.50																		15.00					15.00							
H9572	001	4	1	04	01	H9572_001_4	10	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				31		90	31		90	1	31		90							31		31													3.00		7.50						3.00		9.00						3.00		7.50																		3.00					3.00							
H9572	001	4	1	04	01	H9572_001_4	10	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				31			31				31									31		31		31	14													490.00	30							490.00	30							30																			30				30			30			
H9572	001	4	1	04	01	H9572_001_4	10	3	Preferred Brand	1	4	000001	1	2	100010110110101000000001				31		90	31		90	1	31		90							31				31	14										45.00		112.50						45.00		135.00						45.00		112.50																		45.00							1.45	45.00				
H9572	001	4	1	04	01	H9572_001_4	10	4	Non-Preferred Brand	1	4	100000	1	2	100010110110101000000001				31		90	31		90	1	31		90							31				31	14										95.00		237.50						95.00		285.00						95.00		237.50																		95.00							3.06	95.00				
H9572	001	6	1	04	01	H9572_001_6	10	3	Preferred Brand	1	4	000001	1	2	100010110110101000000001				31		90	31		90	1	31		90							31				31	14										45.00		112.50						45.00		135.00						45.00		112.50																		45.00							1.45	45.00				
H9572	001	6	1	04	01	H9572_001_6	10	4	Non-Preferred Brand	1	4	100000	1	2	100010110110101000000001				31		90	31		90	1	31		90							31				31	14										95.00		237.50						95.00		285.00						95.00		237.50																		95.00							3.06	95.00				
H9572	001	6	1	04	01	H9572_001_6	10	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				31			31				31									31		31		31	14													490.00	30							490.00	30							30																			30				30			30			
H9572	001	6	1	04	01	H9572_001_6	10	2	Non-Preferred Generic	1	4	000100	1	2	000010110110101000000100				31		90	31		90	1	31		90							31		31													15.00		37.50						15.00		45.00						15.00		37.50																		15.00					15.00							
H9572	001	6	1	04	01	H9572_001_6	10	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				31		90	31		90	1	31		90							31		31													3.00		7.50						3.00		9.00						3.00		7.50																		3.00					3.00							
H9572	003	1	1	04	01	H9572_003_1	11	2	Non-Preferred Generic	1	4	000100	1	2	000010110110101000000100				31		90	31		90	1	31		90							31		31													10.00		25.00						10.00		30.00						10.00		25.00																		10.00					10.00							
H9572	003	1	1	04	01	H9572_003_1	11	3	Preferred Brand	1	4	000001	1	2	100010110110101000000001				31		90	31		90	1	31		90							31				31	14										40.00		100.00						40.00		120.00						40.00		100.00																		40.00							1.29	40.00				
H9572	003	1	1	04	01	H9572_003_1	11	4	Non-Preferred Brand	1	4	100000	1	2	100010110110101000000001				31		90	31		90	1	31		90							31				31	14										95.00		237.50						95.00		285.00						95.00		237.50																		95.00							3.06	95.00				
H9572	003	1	1	04	01	H9572_003_1	11	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				31			31				31									31		31		31	14													491.00	30							491.00	30							30																			30				30			30			
H9572	003	1	1	04	01	H9572_003_1	11	1	Preferred Generic	3	4	001000	1	2	000010110110101000000100				31		90	31		90	1	31		90							31		31													3.00		7.50						3.00		9.00						3.00		7.50																		3.00					3.00					1		
H9572	003	1	1	04	01	H9572_003_1	11	2	Non-Preferred Generic	3	4	000100	1	2	000010110110101000000100				31		90	31		90	1	31		90							31		31													10.00		25.00						10.00		30.00						10.00		25.00																		10.00					10.00					1		
H9572	003	1	1	04	01	H9572_003_1	11	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				31		90	31		90	1	31		90							31		31													3.00		7.50						3.00		9.00						3.00		7.50																		3.00					3.00							
H9572	003	2	1	04	01	H9572_003_2	11	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				31		90	31		90	1	31		90							31		31													3.00		7.50						3.00		9.00						3.00		7.50																		3.00					3.00							
H9572	003	2	1	04	01	H9572_003_2	11	2	Non-Preferred Generic	1	4	000100	1	2	000010110110101000000100				31		90	31		90	1	31		90							31		31													10.00		25.00						10.00		30.00						10.00		25.00																		10.00					10.00							
H9572	003	2	1	04	01	H9572_003_2	11	3	Preferred Brand	1	4	000001	1	2	100010110110101000000001				31		90	31		90	1	31		90							31				31	14										40.00		100.00						40.00		120.00						40.00		100.00																		40.00							1.29	40.00				
H9572	003	2	1	04	01	H9572_003_2	11	4	Non-Preferred Brand	1	4	100000	1	2	100010110110101000000001				31		90	31		90	1	31		90							31				31	14										95.00		237.50						95.00		285.00						95.00		237.50																		95.00							3.06	95.00				
H9572	003	2	1	04	01	H9572_003_2	11	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				31			31				31									31		31		31	14													491.00	30							491.00	30							30																			30				30			30			
H9572	003	2	1	04	01	H9572_003_2	11	1	Preferred Generic	3	4	001000	1	2	000010110110101000000100				31		90	31		90	1	31		90							31		31													3.00		7.50						3.00		9.00						3.00		7.50																		3.00					3.00					1		
H9572	003	2	1	04	01	H9572_003_2	11	2	Non-Preferred Generic	3	4	000100	1	2	000010110110101000000100				31		90	31		90	1	31		90							31		31													10.00		25.00						10.00		30.00						10.00		25.00																		10.00					10.00					1		
H9572	003	3	1	04	01	H9572_003_3	11	1	Preferred Generic	3	4	001000	1	2	000010110110101000000100				31		90	31		90	1	31		90							31		31													3.00		7.50						3.00		9.00						3.00		7.50																		3.00					3.00					1		
H9572	003	3	1	04	01	H9572_003_3	11	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				31			31				31									31		31		31	14													491.00	30							491.00	30							30																			30				30			30			
H9572	003	3	1	04	01	H9572_003_3	11	4	Non-Preferred Brand	1	4	100000	1	2	100010110110101000000001				31		90	31		90	1	31		90							31				31	14										95.00		237.50						95.00		285.00						95.00		237.50																		95.00							3.06	95.00				
H9572	003	3	1	04	01	H9572_003_3	11	3	Preferred Brand	1	4	000001	1	2	100010110110101000000001				31		90	31		90	1	31		90							31				31	14										40.00		100.00						40.00		120.00						40.00		100.00																		40.00							1.29	40.00				
H9572	003	3	1	04	01	H9572_003_3	11	2	Non-Preferred Generic	1	4	000100	1	2	000010110110101000000100				31		90	31		90	1	31		90							31		31													10.00		25.00						10.00		30.00						10.00		25.00																		10.00					10.00							
H9572	003	3	1	04	01	H9572_003_3	11	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				31		90	31		90	1	31		90							31		31													3.00		7.50						3.00		9.00						3.00		7.50																		3.00					3.00							
H9572	003	3	1	04	01	H9572_003_3	11	2	Non-Preferred Generic	3	4	000100	1	2	000010110110101000000100				31		90	31		90	1	31		90							31		31													10.00		25.00						10.00		30.00						10.00		25.00																		10.00					10.00					1		
H9572	003	4	1	04	01	H9572_003_4	11	1	Preferred Generic	3	4	001000	1	2	000010110110101000000100				31		90	31		90	1	31		90							31		31													3.00		7.50						3.00		9.00						3.00		7.50																		3.00					3.00					1		
H9572	003	4	1	04	01	H9572_003_4	11	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				31			31				31									31		31		31	14													491.00	30							491.00	30							30																			30				30			30			
H9572	003	4	1	04	01	H9572_003_4	11	4	Non-Preferred Brand	1	4	100000	1	2	100010110110101000000001				31		90	31		90	1	31		90							31				31	14										95.00		237.50						95.00		285.00						95.00		237.50																		95.00							3.06	95.00				
H9572	003	4	1	04	01	H9572_003_4	11	3	Preferred Brand	1	4	000001	1	2	100010110110101000000001				31		90	31		90	1	31		90							31				31	14										40.00		100.00						40.00		120.00						40.00		100.00																		40.00							1.29	40.00				
H9572	003	4	1	04	01	H9572_003_4	11	2	Non-Preferred Generic	1	4	000100	1	2	000010110110101000000100				31		90	31		90	1	31		90							31		31													10.00		25.00						10.00		30.00						10.00		25.00																		10.00					10.00							
H9572	003	4	1	04	01	H9572_003_4	11	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				31		90	31		90	1	31		90							31		31													3.00		7.50						3.00		9.00						3.00		7.50																		3.00					3.00							
H9572	003	4	1	04	01	H9572_003_4	11	2	Non-Preferred Generic	3	4	000100	1	2	000010110110101000000100				31		90	31		90	1	31		90							31		31													10.00		25.00						10.00		30.00						10.00		25.00																		10.00					10.00					1		
H9572	003	6	1	04	01	H9572_003_6	11	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				31		90	31		90	1	31		90							31		31													3.00		7.50						3.00		9.00						3.00		7.50																		3.00					3.00							
H9572	003	6	1	04	01	H9572_003_6	11	2	Non-Preferred Generic	1	4	000100	1	2	000010110110101000000100				31		90	31		90	1	31		90							31		31													10.00		25.00						10.00		30.00						10.00		25.00																		10.00					10.00							
H9572	003	6	1	04	01	H9572_003_6	11	3	Preferred Brand	1	4	000001	1	2	100010110110101000000001				31		90	31		90	1	31		90							31				31	14										40.00		100.00						40.00		120.00						40.00		100.00																		40.00							1.29	40.00				
H9572	003	6	1	04	01	H9572_003_6	11	4	Non-Preferred Brand	1	4	100000	1	2	100010110110101000000001				31		90	31		90	1	31		90							31				31	14										95.00		237.50						95.00		285.00						95.00		237.50																		95.00							3.06	95.00				
H9572	003	6	1	04	01	H9572_003_6	11	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				31			31				31									31		31		31	14													491.00	30							491.00	30							30																			30				30			30			
H9572	003	6	1	04	01	H9572_003_6	11	1	Preferred Generic	3	4	001000	1	2	000010110110101000000100				31		90	31		90	1	31		90							31		31													3.00		7.50						3.00		9.00						3.00		7.50																		3.00					3.00					1		
H9572	003	6	1	04	01	H9572_003_6	11	2	Non-Preferred Generic	3	4	000100	1	2	000010110110101000000100				31		90	31		90	1	31		90							31		31													10.00		25.00						10.00		30.00						10.00		25.00																		10.00					10.00					1		
H9615	002	0	1	04	01	H9615_002_0	9	5	Select Care Drugs	1	4	010010	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00				
H9615	002	0	1	04	01	H9615_002_0	9	4	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					33.00	33																							33																			33				33			33			
H9615	002	0	1	04	01	H9615_002_0	9	3	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		90.00		270.00																						90.00		180.00																		90.00					90.00			90.00				
H9615	002	0	1	04	01	H9615_002_0	9	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		35.00		105.00																						35.00		70.00																		35.00								35.00				
H9615	002	0	1	04	01	H9615_002_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					8.00		24.00																						8.00		16.00																		8.00					8.00							
H9615	002	0	1	04	01	H9615_002_0	9	5	Select Care Drugs	3	4	010010	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00		1		
H9615	007	0	1	04	01	H9615_007_0	5	5	Select Care Drugs	3	4	010010	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00		1		
H9615	007	0	1	04	01	H9615_007_0	5	5	Select Care Drugs	1	4	010010	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00				
H9615	007	0	1	04	01	H9615_007_0	5	4	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					33.00	33																							33																			33				33			33			
H9615	007	0	1	04	01	H9615_007_0	5	3	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		90.00		270.00																						90.00		180.00																		90.00					90.00			90.00				
H9615	007	0	1	04	01	H9615_007_0	5	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00							
H9615	007	0	1	04	01	H9615_007_0	5	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		35.00		105.00																						35.00		70.00																		35.00								35.00				
H9670	004	0	1	04	01	H9670_004_0	13	1	Generic	1	3	010000		2	010100000010001000000110	31		90							1			90							31		31	14				9.00		18.00																								18.00																		9.00					9.00							
H9670	004	0	1	04	01	H9670_004_0	13	2	Preferred Brand	1	3	000001		2	110100000010001000000001	31		90							1			90							31				31	14		44.00		121.00																								110.00																		44.00								44.00				
H9670	004	0	1	04	01	H9670_004_0	13	3	Non-Preferred Brand	1	3	100000		2	110100000010001000000001	31		90							1			90							31				31	14		95.00		285.00																								285.00																		95.00								95.00				
H9670	004	0	1	04	01	H9670_004_0	13	4	Specialty Tier	1	3	010010		1	110000000010100000000111	31										31									31		31	14	31	14					760.00	33																							33																			33				33			33			
H9670	004	0	1	04	01	H9670_004_0	13	5	Select Care Drugs	1	3	010000		2	010100000010001000000110	31		90							1			90							31		31	14				0.00		0.00																								0.00																		0.00					0.00							
H9730	001	0	1	01	01	H9730_001_0	6	3	Non-Preferred Brand	1	4	110000	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		95.00	190.00	285.00																													95.00	190.00	190.00							285.00				95.00					95.00			95.00				
H9730	001	0	1	01	01	H9730_001_0	6	2	Preferred Brand	1	4	010001	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		45.00	90.00	135.00																													45.00	90.00	90.00							135.00				45.00					45.00			45.00				
H9730	001	0	1	01	01	H9730_001_0	6	1	Preferred Generic	1	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
H9730	001	0	1	01	01	H9730_001_0	6	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	31													31			31			31		31		31	14					707.00	25																														25							25					25				25			25			
H9730	002	0	1	02	01	H9730_002_0	7	3	Non-Preferred Brand	1	4	100000	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		70.00	140.00	210.00																													70.00	140.00	140.00							210.00				70.00								70.00				
H9730	002	0	1	02	01	H9730_002_0	7	2	Preferred Brand	1	4	000001	1	2	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14		35.00	70.00	105.00																													35.00	70.00	70.00							105.00				35.00								35.00				
H9730	002	0	1	02	01	H9730_002_0	7	1	Generic	1	4	010010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		3.00	6.00	9.00																													3.00	6.00	0.00							9.00				3.00					3.00			3.00				
H9730	002	0	1	02	01	H9730_002_0	7	4	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
H9834	001	0	1	01	01	H9834_001_0	2	4	Non-Preferred Brand	1	3	100000		2	110100000010000000000001	30		90							1										30				31	14		95.00		285.00																																										95.00								95.00				
H9834	001	0	1	01	01	H9834_001_0	2	2	Non-Preferred Generic	1	3	000100		2	010100000010000000000100	30		90							1										30		31					30.00		90.00																																										30.00					30.00							
H9834	001	0	1	01	01	H9834_001_0	2	1	Preferred Generic	1	3	001000		2	010100000010000000000100	30		90							1										30		31					8.00		24.00																																										8.00					8.00							
H9834	001	0	1	01	01	H9834_001_0	2	3	Preferred Brand	1	3	000001		2	110100000010000000000001	30		90							1										30				31	14		45.00		135.00																																										45.00								45.00				
H9834	001	0	1	01	01	H9834_001_0	2	5	Specialty Tier	1	3	010010		1	110100000010000000000101	30		90							1										30		31		31	14					172.31	31		31																																								31				31			31			
H9834	003	0	1	01	01	H9834_003_0	3	4	Non-Preferred Brand	1	3	100000		2	110100000010000000000001	30		90							1										30				31	14		95.00		285.00																																										95.00								95.00				
H9834	003	0	1	01	01	H9834_003_0	3	3	Preferred Brand	1	3	000001		2	110100000010000000000001	30		90							1										30				31	14		45.00		135.00																																										45.00								45.00				
H9834	003	0	1	01	01	H9834_003_0	3	5	Specialty Tier	1	3	010010		1	110100000010000000000101	30		90							1										30		31		31	14					297.92	30		30																																								30				30			30			
H9834	003	0	1	01	01	H9834_003_0	3	2	Non-Preferred Generic	1	3	000100		2	010100000010000000000100	30		90							1										30		31					33.00		99.00																																										33.00					33.00							
H9834	003	0	1	01	01	H9834_003_0	3	1	Preferred Generic	1	3	001000		2	010100000010000000000100	30		90							1										30		31					10.00		30.00																																										10.00					10.00							
H9847	001	0	1	04	01	H9847_001_0	9	5	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													811.08	33							811.08	33																										33				33			33			
H9847	001	0	1	04	01	H9847_001_0	9	4	Non-Preferred Brand	1	4	100100	1	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										85.00		255.00						85.00		255.00						85.00		255.00																		85.00					85.00			85.00				
H9847	001	0	1	04	01	H9847_001_0	9	3	Preferred Brand	1	4	000001	1	2	100010110110101000000001				30		90	30		90	2	30		90							30				31	14										45.00		135.00						45.00		135.00						45.00		135.00																		45.00								45.00				
H9847	001	0	1	04	01	H9847_001_0	9	2	Non-Preferred Generic	1	4	000100	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													22.00		66.00						25.00		75.00						22.00		66.00																		25.00					25.00							
H9847	001	0	1	04	01	H9847_001_0	9	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													3.00		9.00						4.00		12.00						3.00		9.00																		4.00					4.00							
H9847	005	0	1	04	01	H9847_005_0	10	5	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													756.32	33							756.32	33																										33				33			33			
H9847	005	0	1	04	01	H9847_005_0	10	3	Preferred Brand	1	4	000001	1	2	100010110110101000000001				30		90	30		90	2	30		90							30				31	14										45.00		135.00						45.00		135.00						45.00		112.50																		45.00								45.00				
H9847	005	0	1	04	01	H9847_005_0	10	4	Non-Preferred Brand	1	4	100100	1	2	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14										85.00		255.00						90.00		270.00						85.00		212.50																		90.00					90.00			90.00				
H9847	005	0	1	04	01	H9847_005_0	10	2	Non-Preferred Generic	1	4	000100	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													18.00		54.00						22.00		66.00						18.00		36.00																		22.00					22.00							
H9847	005	0	1	04	01	H9847_005_0	10	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				30		90	30		90	2	30		90							30		31													3.00		9.00						4.00		12.00						3.00		4.50																		4.00					4.00							
H9859	002	0	1	02	01	H9859_002_0	8	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		35.00		105.00																						35.00		70.00																		35.00								35.00				
H9859	002	0	1	02	01	H9859_002_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00							
H9859	002	0	1	02	01	H9859_002_0	8	3	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		90.00		270.00																						90.00		180.00																		90.00					90.00			90.00				
H9859	002	0	1	02	01	H9859_002_0	8	4	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					33.00	33																							33																			33				33			33			
H9859	002	0	1	02	01	H9859_002_0	8	5	Select Care Drugs	1	4	010010	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00				
H9859	002	0	1	02	01	H9859_002_0	8	5	Select Care Drugs	3	4	010010	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00		1		
H9859	004	0	1	02	01	H9859_004_0	10	5	Select Care Drugs	1	4	010010	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		6.00		18.00																						6.00		12.00																		6.00					6.00			6.00				
H9859	004	0	1	02	01	H9859_004_0	10	4	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					25.00	25																							25																			25				25			25			
H9859	004	0	1	02	01	H9859_004_0	10	3	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		95.00		285.00																						95.00		190.00																		95.00					95.00			95.00				
H9859	004	0	1	02	01	H9859_004_0	10	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00							
H9859	004	0	1	02	01	H9859_004_0	10	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		45.00		135.00																						45.00		90.00																		45.00								45.00				
H9859	013	0	1	02	01	H9859_013_0	8	5	Select Care Drugs	3	4	010010	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00		1		
H9859	013	0	1	02	01	H9859_013_0	8	5	Select Care Drugs	1	4	010010	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		0.00		0.00																						0.00		0.00																		0.00					0.00			0.00				
H9859	013	0	1	02	01	H9859_013_0	8	4	Specialty Tier	1	4	010010	1	1	110000000010100000000101	30										30									30		31		31	14					33.00	33																							33																			33				33			33			
H9859	013	0	1	02	01	H9859_013_0	8	3	Non-Preferred Brand	1	4	100100	1	2	110100000010101000000101	30		90							2	30		90							30		31		31	14		90.00		270.00																						90.00		180.00																		90.00					90.00			90.00				
H9859	013	0	1	02	01	H9859_013_0	8	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							2	30		90							30				31	14		35.00		105.00																						35.00		70.00																		35.00								35.00				
H9859	013	0	1	02	01	H9859_013_0	8	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							2	30		90							30		31					10.00		30.00																						10.00		20.00																		10.00					10.00							
H9915	001	0	1	01	01	H9915_001_0	7	1	Generic	1	4	010000	1	2	000011111110111000000110				30	60	90	30	60	90	1	30	60	90							30		31	7												4.00	7.00	10.00						8.00	14.00	20.00						4.00	7.00	10.00																		8.00					8.00							
H9915	001	0	1	01	01	H9915_001_0	7	2	Preferred Brand	1	4	000001	1	2	100011111110111000000001				30	60	90	30	60	90	1	30	60	90							30				31	7										40.00	75.00	110.00						45.00	85.00	125.00						40.00	75.00	110.00																		45.00								45.00				
H9915	001	0	1	01	01	H9915_001_0	7	3	Non-Preferred Brand	1	4	100000	1	2	100011111110111000000001				30	60	90	30	60	90	1	30	60	90							30				31	7										80.00	160.00	240.00						95.00	190.00	285.00						80.00	160.00	240.00																		95.00								95.00				
H9915	001	0	1	01	01	H9915_001_0	7	4	Specialty Tier	1	4	010010	1	1	100010010010100000000111				30			30				30									30		31	7	31	7													619.60	33							619.60	33							33																			33				33			33			
H9915	002	0	1	01	01	H9915_002_0	7	3	Non-Preferred Brand	1	4	100000	1	2	100011111110111000000001				30	60	90	30	60	90	1	30	60	90							30				31	7										80.00	160.00	240.00						95.00	190.00	285.00						80.00	160.00	240.00																		95.00								95.00				
H9915	002	0	1	01	01	H9915_002_0	7	4	Specialty Tier	1	4	010010	1	1	100010010010100000000111				30			30				30									30		31	7	31	7													603.50	33							603.50	33							33																			33				33			33			
H9915	002	0	1	01	01	H9915_002_0	7	2	Preferred Brand	1	4	000001	1	2	100011111110111000000001				30	60	90	30	60	90	1	30	60	90							30				31	7										40.00	75.00	110.00						45.00	85.00	125.00						40.00	75.00	110.00																		45.00								45.00				
H9915	002	0	1	01	01	H9915_002_0	7	1	Generic	1	4	010000	1	2	000011111110111000000110				30	60	90	30	60	90	1	30	60	90							30		31	7												4.00	7.00	10.00						8.00	14.00	20.00						4.00	7.00	10.00																		8.00					8.00							
H9947	001	0	1	04	01	H9947_001_0	10	2	Non-Preferred Generic	1	3	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				10.00	20.00	30.00																						10.00	20.00	15.00																		10.00					10.00							
H9947	001	0	1	04	01	H9947_001_0	10	1	Preferred Generic	1	3	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				5.00	10.00	15.00																						5.00	10.00	7.50																		5.00					5.00							
H9947	001	0	1	04	01	H9947_001_0	10	4	Non-Preferred Brand	1	3	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		93.00	186.00	279.00																						93.00	186.00	232.50																		93.00					93.00			93.00				
H9947	001	0	1	04	01	H9947_001_0	10	5	Injectable Drugs	1	3	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					82.00	33	33	33																					33	33	33																	33				33			33			
H9947	001	0	1	04	01	H9947_001_0	10	6	Specialty Tier	1	3	010010		1	110000000010100000000111	30										30									30		34	14	34	14					711.00	33																							33																			33				33			33			
H9947	001	0	1	04	01	H9947_001_0	10	3	Preferred Brand	1	3	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00					45.00			45.00				
H9947	002	0	1	04	01	H9947_002_0	10	6	Specialty Tier	1	3	010010		1	110000000010100000000111	30										30									30		34	14	34	14					711.00	33																							33																			33				33			33			
H9947	002	0	1	04	01	H9947_002_0	10	5	Injectable Drugs	1	3	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					82.00	33	33	33																					33	33	33																	33				33			33			
H9947	002	0	1	04	01	H9947_002_0	10	4	Non-Preferred Brand	1	3	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		93.00	186.00	279.00																						93.00	186.00	232.50																		93.00					93.00			93.00				
H9947	002	0	1	04	01	H9947_002_0	10	1	Preferred Generic	1	3	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				5.00	10.00	15.00																						5.00	10.00	7.50																		5.00					5.00							
H9947	002	0	1	04	01	H9947_002_0	10	2	Non-Preferred Generic	1	3	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				10.00	20.00	30.00																						10.00	20.00	15.00																		10.00					10.00							
H9947	002	0	1	04	01	H9947_002_0	10	3	Preferred Brand	1	3	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00					45.00			45.00				
H9947	004	0	1	04	01	H9947_004_0	11	1	Preferred Generic	1	3	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				4.00	8.00	12.00																						4.00	8.00	6.00																		4.00					4.00							
H9947	004	0	1	04	01	H9947_004_0	11	2	Non-Preferred Generic	1	3	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				8.00	16.00	24.00																						8.00	16.00	12.00																		8.00					8.00							
H9947	004	0	1	04	01	H9947_004_0	11	3	Preferred Brand	1	3	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		41.00	82.00	123.00																						41.00	82.00	102.50																		41.00					41.00			41.00				
H9947	004	0	1	04	01	H9947_004_0	11	6	Specialty Tier	1	3	010010		1	110000000010100000000111	30										30									30		34	14	34	14					711.00	33																							33																			33				33			33			
H9947	004	0	1	04	01	H9947_004_0	11	4	Non-Preferred Brand	1	3	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
H9947	004	0	1	04	01	H9947_004_0	11	5	Injectable Drugs	1	3	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					82.00	33	33	33																					33	33	33																	33				33			33			
R3175	001	0	1	31	11	R3175_001_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
R3175	001	0	1	31	11	R3175_001_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					447.00	33		33																														33							33			33				33			33			
R3175	001	0	1	31	11	R3175_001_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
R3175	001	0	1	31	11	R3175_001_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
R3175	001	0	1	31	11	R3175_001_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
R3332	001	0	1	31	11	R3332_001_0	9	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		95.00		285.00																						95.00		285.00																		95.00								95.00				
R3332	001	0	1	31	11	R3332_001_0	9	5	Specialty Tier	1	4	100101	1	1	110100000010101000000111	31		90							1	31		90							31		31	14	31	14					1602.51	33		33																					33		33																	33				33			33			
R3332	001	0	1	31	11	R3332_001_0	9	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		45.00		135.00																						45.00		135.00																		45.00								45.00				
R3332	001	0	1	31	11	R3332_001_0	9	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000110	31		90							1	31		90							31		31	14				10.00		30.00																						5.00		15.00																		10.00					10.00							
R3332	001	0	1	31	11	R3332_001_0	9	1	Preferred Generic	1	4	001000	1	2	010100000010101000000110	31		90							1	31		90							31		31	14				6.00		18.00																						0.00		0.00																		6.00					6.00							
R3444	009	0	1	31	11	R3444_009_0	6	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					1008.00	33	33	33																					33	33	33																	33				33			33			
R3444	009	0	1	31	11	R3444_009_0	6	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
R3444	009	0	1	31	11	R3444_009_0	6	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					8.00	16.00	24.00																						8.00	16.00	20.00																		8.00					8.00							
R3444	009	0	1	31	11	R3444_009_0	6	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
R3444	012	0	1	31	11	R3444_012_0	6	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
R3444	012	0	1	31	11	R3444_012_0	6	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
R3444	012	0	1	31	11	R3444_012_0	6	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					993.00	33	33	33																					33	33	33																	33				33			33			
R3444	012	0	1	31	11	R3444_012_0	6	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					8.00	16.00	24.00																						8.00	16.00	20.00																		8.00					8.00							
R3444	022	0	1	31	11	R3444_022_0	5	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					877.00	33	33	33																					33	33	33																	33				33			33			
R3444	022	0	1	31	11	R3444_022_0	5	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
R3444	022	0	1	31	11	R3444_022_0	5	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
R3444	022	0	1	31	11	R3444_022_0	5	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					8.00	16.00	24.00																						8.00	16.00	20.00																		8.00					8.00							
R5287	001	0	1	31	11	R5287_001_0	6	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
R5287	001	0	1	31	11	R5287_001_0	6	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
R5287	001	0	1	31	11	R5287_001_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
R5287	001	0	1	31	11	R5287_001_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					0.00		0.00																															0.00							0.00				0.00					0.00							
R5287	001	0	1	31	11	R5287_001_0	6	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					561.00	33		33																														33							33			33				33			33			
R5342	001	0	1	31	11	R5342_001_0	6	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
R5342	001	0	1	31	11	R5342_001_0	6	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
R5342	001	0	1	31	11	R5342_001_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					6.00		18.00																															12.00							18.00				6.00					6.00							
R5342	001	0	1	31	11	R5342_001_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					3.00		9.00																															6.00							9.00				3.00					3.00							
R5342	001	0	1	31	11	R5342_001_0	6	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					523.00	33		33																														33							33			33				33			33			
R5826	001	0	1	31	11	R5826_001_0	6	4	Non-Preferred Brand	1	3	110000		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
R5826	001	0	1	31	11	R5826_001_0	6	5	Specialty Tier	1	3	010010		1	110000000010000100100101	30													30			30			30		31		31	14					782.00	30																														30							30					30				30			30			
R5826	001	0	1	31	11	R5826_001_0	6	3	Preferred Brand	1	3	000101		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		38.00		114.00																													38.00		104.00					38.00		114.00				38.00					38.00			38.00				
R5826	001	0	1	31	11	R5826_001_0	6	2	Non-Preferred Generic	1	3	000101		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00				
R5826	001	0	1	31	11	R5826_001_0	6	1	Preferred Generic	1	3	001010		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00				
R5826	002	0	1	31	11	R5826_002_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
R5826	002	0	1	31	11	R5826_002_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
R5826	002	0	1	31	11	R5826_002_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
R5826	002	0	1	31	11	R5826_002_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
R5826	002	0	1	31	11	R5826_002_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					981.00	33																														33							33					33				33			33	2	3	
R5826	002	0	1	31	11	R5826_002_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
R5826	002	0	1	31	11	R5826_002_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
R5826	002	0	1	31	11	R5826_002_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
R5826	002	0	1	31	11	R5826_002_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
R5826	002	0	1	31	11	R5826_002_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					755.00	33																														33							33					33				33			33			
R5826	003	0	1	31	11	R5826_003_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00		2	3	
R5826	003	0	1	31	11	R5826_003_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		11.00		33.00																													0.00		0.00					11.00		33.00				11.00					11.00			11.00		2	2	
R5826	003	0	1	31	11	R5826_003_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
R5826	003	0	1	31	11	R5826_003_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00		2	3	
R5826	003	0	1	31	11	R5826_003_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		5.00		15.00																													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
R5826	003	0	1	31	11	R5826_003_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					825.00	33																														33							33					33				33			33			
R5826	003	0	1	31	11	R5826_003_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
R5826	003	0	1	31	11	R5826_003_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
R5826	003	0	1	31	11	R5826_003_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		11.00		33.00																													0.00		0.00					11.00		33.00				11.00					11.00			11.00				
R5826	003	0	1	31	11	R5826_003_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					983.00	33																														33							33					33				33			33	2	3	
R5826	005	0	1	31	11	R5826_005_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00		2	2	
R5826	005	0	1	31	11	R5826_005_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
R5826	005	0	1	31	11	R5826_005_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00		2	3	
R5826	005	0	1	31	11	R5826_005_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					875.00	33																														33							33					33				33			33	2	3	
R5826	005	0	1	31	11	R5826_005_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		3.00		9.00																													0.00		0.00					3.00		9.00				3.00					3.00			3.00				
R5826	005	0	1	31	11	R5826_005_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00				
R5826	005	0	1	31	11	R5826_005_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
R5826	005	0	1	31	11	R5826_005_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00				
R5826	005	0	1	31	11	R5826_005_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					779.00	33																														33							33					33				33			33			
R5826	005	0	1	31	11	R5826_005_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		3.00		9.00																													0.00		0.00					3.00		9.00				3.00					3.00			3.00		2	3	1
R5826	006	0	1	31	11	R5826_006_0	5	3	Non-Preferred Brand	3	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00		2	3	
R5826	006	0	1	31	11	R5826_006_0	5	2	Preferred Brand	3	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00		2	2	
R5826	006	0	1	31	11	R5826_006_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00		2	3	1
R5826	006	0	1	31	11	R5826_006_0	5	4	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					764.00	33																														33							33					33				33			33			
R5826	006	0	1	31	11	R5826_006_0	5	3	Non-Preferred Brand	1	4	100100	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		80.00		240.00																													80.00		230.00					80.00		240.00				80.00					80.00			80.00				
R5826	006	0	1	31	11	R5826_006_0	5	2	Preferred Brand	1	4	010001	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		40.00		120.00																													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
R5826	006	0	1	31	11	R5826_006_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		8.00		24.00																													0.00		0.00					8.00		24.00				8.00					8.00			8.00				
R5826	006	0	1	31	11	R5826_006_0	5	4	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					896.00	33																														33							33					33				33			33	2	3	
R5826	007	0	1	31	11	R5826_007_0	11	2	Non-Preferred Generic	1	3	000101		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
R5826	007	0	1	31	11	R5826_007_0	11	5	Specialty Tier	1	3	010010		1	110000000010000100100101	30													30			30			30		31		31	14					632.00	29																														29							29					29				29			29			
R5826	007	0	1	31	11	R5826_007_0	11	4	Non-Preferred Brand	1	3	110000		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
R5826	007	0	1	31	11	R5826_007_0	11	3	Preferred Brand	1	3	000101		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
R5826	007	0	1	31	11	R5826_007_0	11	1	Preferred Generic	1	3	001010		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
R5826	008	0	1	31	11	R5826_008_0	6	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
R5826	008	0	1	31	11	R5826_008_0	6	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
R5826	008	0	1	31	11	R5826_008_0	6	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
R5826	008	0	1	31	11	R5826_008_0	6	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	
R5826	008	0	1	31	11	R5826_008_0	6	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
R5826	008	0	1	31	11	R5826_008_0	6	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
R5826	008	0	1	31	11	R5826_008_0	6	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
R5826	008	0	1	31	11	R5826_008_0	6	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
R5826	008	0	1	31	11	R5826_008_0	6	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					944.00	33																														33							33					33				33			33	2	3	
R5826	008	0	1	31	11	R5826_008_0	6	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					862.00	33																														33							33					33				33			33			
R5826	011	0	1	31	11	R5826_011_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00				
R5826	011	0	1	31	11	R5826_011_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
R5826	011	0	1	31	11	R5826_011_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
R5826	011	0	1	31	11	R5826_011_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00				
R5826	011	0	1	31	11	R5826_011_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					899.00	33																														33							33					33				33			33			
R5826	011	0	1	31	11	R5826_011_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00		2	3	1
R5826	011	0	1	31	11	R5826_011_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00		2	2	
R5826	011	0	1	31	11	R5826_011_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
R5826	011	0	1	31	11	R5826_011_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		85.00		255.00																													85.00		245.00					85.00		255.00				85.00					85.00			85.00		2	3	
R5826	011	0	1	31	11	R5826_011_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					1014.00	33																														33							33					33				33			33	2	3	
R5826	012	0	1	31	11	R5826_012_0	8	3	Preferred Brand	1	3	000101		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
R5826	012	0	1	31	11	R5826_012_0	8	1	Preferred Generic	1	3	001010		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		7.00		21.00																													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
R5826	012	0	1	31	11	R5826_012_0	8	2	Non-Preferred Generic	1	3	000101		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
R5826	012	0	1	31	11	R5826_012_0	8	4	Non-Preferred Brand	1	3	110000		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		89.00		267.00																													89.00		257.00					89.00		267.00				89.00					89.00			89.00				
R5826	012	0	1	31	11	R5826_012_0	8	5	Specialty Tier	1	3	010010		1	110000000010000100100101	30													30			30			30		31		31	14					742.00	30																														30							30					30				30			30			
R5826	014	0	1	31	11	R5826_014_0	5	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
R5826	014	0	1	31	11	R5826_014_0	5	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					775.00	33																														33							33					33				33			33	2	3	
R5826	014	0	1	31	11	R5826_014_0	5	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00				
R5826	014	0	1	31	11	R5826_014_0	5	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
R5826	014	0	1	31	11	R5826_014_0	5	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
R5826	014	0	1	31	11	R5826_014_0	5	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
R5826	014	0	1	31	11	R5826_014_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					707.00	33																														33							33					33				33			33			
R5826	014	0	1	31	11	R5826_014_0	5	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		0.00		0.00																													0.00		0.00					0.00		0.00				0.00					0.00			0.00		2	3	1
R5826	014	0	1	31	11	R5826_014_0	5	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		10.00		30.00																													0.00		0.00					10.00		30.00				10.00					10.00			10.00		2	2	
R5826	014	0	1	31	11	R5826_014_0	5	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
R5826	074	0	1	31	11	R5826_074_0	7	4	Non-Preferred Brand	1	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
R5826	074	0	1	31	11	R5826_074_0	7	5	Specialty Tier	1	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					639.00	33																														33							33					33				33			33			
R5826	074	0	1	31	11	R5826_074_0	7	2	Non-Preferred Generic	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
R5826	074	0	1	31	11	R5826_074_0	7	1	Preferred Generic	1	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
R5826	074	0	1	31	11	R5826_074_0	7	5	Specialty Tier	3	4	010010	1	1	110000000010000100100101	30													30			30			30		31		31	14					703.00	33																														33							33					33				33			33	2	3	
R5826	074	0	1	31	11	R5826_074_0	7	4	Non-Preferred Brand	3	4	110000	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		95.00		285.00																													95.00		275.00					95.00		285.00				95.00					95.00			95.00		2	3	
R5826	074	0	1	31	11	R5826_074_0	7	3	Preferred Brand	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00		2	2	
R5826	074	0	1	31	11	R5826_074_0	7	3	Preferred Brand	1	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
R5826	074	0	1	31	11	R5826_074_0	7	1	Preferred Generic	3	4	001010	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		6.00		18.00																													0.00		0.00					6.00		18.00				6.00					6.00			6.00		2	3	1
R5826	074	0	1	31	11	R5826_074_0	7	2	Non-Preferred Generic	3	4	000101	1	2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		15.00		45.00																													0.00		0.00					15.00		45.00				15.00					15.00			15.00		2	2	
R5826	077	0	1	31	11	R5826_077_0	6	5	Specialty Tier	1	3	010010		1	110000000010000100100101	30													30			30			30		31		31	14					819.00	29																														29							29					29				29			29			
R5826	077	0	1	31	11	R5826_077_0	6	4	Non-Preferred Brand	1	3	110000		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		90.00		270.00																													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
R5826	077	0	1	31	11	R5826_077_0	6	2	Non-Preferred Generic	1	3	000101		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		12.00		36.00																													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
R5826	077	0	1	31	11	R5826_077_0	6	3	Preferred Brand	1	3	000101		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		45.00		135.00																													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
R5826	077	0	1	31	11	R5826_077_0	6	1	Preferred Generic	1	3	001010		2	110100000010000101101101	30		90							2				30		90	30		90	30		31		31	14		4.00		12.00																													0.00		0.00					4.00		12.00				4.00					4.00			4.00				
R5941	008	0	1	31	11	R5941_008_0	16	4	Non-Preferred Brand	1	3	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
R5941	008	0	1	31	11	R5941_008_0	16	1	Preferred Generic	1	3	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				4.00	8.00	12.00																						4.00	8.00	6.00																		4.00					4.00							
R5941	008	0	1	31	11	R5941_008_0	16	2	Non-Preferred Generic	1	3	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				12.00	24.00	36.00																						12.00	24.00	18.00																		12.00					12.00							
R5941	008	0	1	31	11	R5941_008_0	16	3	Preferred Brand	1	3	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00					45.00			45.00				
R5941	008	0	1	31	11	R5941_008_0	16	5	Injectable Drugs	1	3	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					85.00	33	33	33																					33	33	33																	33				33			33			
R5941	008	0	1	31	11	R5941_008_0	16	6	Specialty Tier	1	3	010010		1	110000000010100000000111	30										30									30		34	14	34	14					817.00	33																							33																			33				33			33			
R5941	009	0	1	31	11	R5941_009_0	15	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					820.00	33																							33																			33				33			33			
R5941	009	0	1	31	11	R5941_009_0	15	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00					95.00			95.00				
R5941	009	0	1	31	11	R5941_009_0	15	5	Injectable Drugs	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					68.00	33	33	33																					33	33	33																	33				33			33			
R5941	009	0	1	31	11	R5941_009_0	15	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				4.00	8.00	12.00																						4.00	8.00	6.00																		4.00					4.00							
R5941	009	0	1	31	11	R5941_009_0	15	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				12.00	24.00	36.00																						12.00	24.00	18.00																		12.00					12.00							
R5941	009	0	1	31	11	R5941_009_0	15	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00					45.00			45.00				
R6801	009	0	1	31	11	R6801_009_0	5	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
R6801	009	0	1	31	11	R6801_009_0	5	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					701.00	33	33	33																					33	33	33																	33				33			33			
R6801	009	0	1	31	11	R6801_009_0	5	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
R6801	009	0	1	31	11	R6801_009_0	5	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					8.00	16.00	24.00																						8.00	16.00	20.00																		8.00					8.00							
R6801	012	0	1	31	11	R6801_012_0	5	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					8.00	16.00	24.00																						8.00	16.00	20.00																		8.00					8.00							
R6801	012	0	1	31	11	R6801_012_0	5	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					865.00	33	33	33																					33	33	33																	33				33			33			
R6801	012	0	1	31	11	R6801_012_0	5	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
R6801	012	0	1	31	11	R6801_012_0	5	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
R6801	022	0	1	31	11	R6801_022_0	4	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					888.00	33	33	33																					33	33	33																	33				33			33			
R6801	022	0	1	31	11	R6801_022_0	4	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
R6801	022	0	1	31	11	R6801_022_0	4	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
R6801	022	0	1	31	11	R6801_022_0	4	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					8.00	16.00	24.00																						8.00	16.00	20.00																		8.00					8.00							
R7439	001	0	1	31	11	R7439_001_0	7	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				34	14		45.00		135.00																								90.00																		45.00								45.00				
R7439	001	0	1	31	11	R7439_001_0	7	1	Generic	1	4	010000	1	2	010100000010001000000100	30		90							2			90							30		34					6.00		18.00																								12.00																		6.00					6.00							
R7439	001	0	1	31	11	R7439_001_0	7	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							2			90							30				34	14		85.00		255.00																								170.00																		85.00								85.00				
R7439	001	0	1	31	11	R7439_001_0	7	4	Specialty Tier	1	4	010010	1	1	110100000010000000000101	30		90							2										30		34		34	14					486.60	33		33																																								33				33			33			
R7439	003	0	1	31	11	R7439_003_0	9	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				34	14		30.00		90.00																								60.00																		30.00								30.00				
R7439	003	0	1	31	11	R7439_003_0	9	1	Generic	1	4	010000	1	2	010100000010001000000100	30		90							2			90							30		34					4.00		12.00																								4.00																		4.00					4.00							
R7439	003	0	1	31	11	R7439_003_0	9	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							2			90							30				34	14		65.00		195.00																								130.00																		65.00								65.00				
R7439	003	0	1	31	11	R7439_003_0	9	4	Specialty Tier	1	4	010010	1	1	110100000010000000000101	30		90							2										30		34		34	14					384.55	25		25																																								25				25			25			
R7444	001	0	1	31	11	R7444_001_0	7	1	Preferred Generic	1	4	001000	1	2	010100000010000001001100	31		90							1						90			90	31		31					5.00		15.00																															10.00							15.00				5.00					5.00							
R7444	001	0	1	31	11	R7444_001_0	7	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000001001100	31		90							1						90			90	31		31					8.00		24.00																															16.00							24.00				8.00					8.00							
R7444	001	0	1	31	11	R7444_001_0	7	3	Preferred Brand	1	4	010001	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		45.00		135.00																															125.00							135.00				45.00					45.00			45.00				
R7444	001	0	1	31	11	R7444_001_0	7	4	Non-Preferred Brand	1	4	100100	1	2	110100000010000001001101	31		90							1						90			90	31		31		31	14		95.00		285.00																															275.00							285.00				95.00					95.00			95.00				
R7444	001	0	1	31	11	R7444_001_0	7	5	Specialty Tier	1	4	010010	1	1	110100000010000001001101	31		90							1						90			90	31		31		31	14					505.00	33		33																														33							33			33				33			33			
R9896	009	0	1	31	11	R9896_009_0	5	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
R9896	009	0	1	31	11	R9896_009_0	5	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					887.00	33	33	33																					33	33	33																	33				33			33			
R9896	009	0	1	31	11	R9896_009_0	5	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
R9896	009	0	1	31	11	R9896_009_0	5	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					8.00	16.00	24.00																						8.00	16.00	20.00																		8.00					8.00							
R9896	012	0	1	31	11	R9896_012_0	6	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					8.00	16.00	24.00																						8.00	16.00	20.00																		8.00					8.00							
R9896	012	0	1	31	11	R9896_012_0	6	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					768.00	33	33	33																					33	33	33																	33				33			33			
R9896	012	0	1	31	11	R9896_012_0	6	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
R9896	012	0	1	31	11	R9896_012_0	6	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
R9896	023	0	1	31	11	R9896_023_0	5	4	Specialty Tier	1	4	010010	1	1	111100000010111000000101	30	60	90							1	30	60	90							30		31		31	14					868.00	33	33	33																					33	33	33																	33				33			33			
R9896	023	0	1	31	11	R9896_023_0	5	3	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		95.00	190.00	285.00																						95.00	190.00	237.50																		95.00								95.00				
R9896	023	0	1	31	11	R9896_023_0	5	2	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		45.00	90.00	135.00																						45.00	90.00	112.50																		45.00								45.00				
R9896	023	0	1	31	11	R9896_023_0	5	1	Generic	1	4	010000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					8.00	16.00	24.00																						8.00	16.00	20.00																		8.00					8.00							
S0043	009	0		29	10	S0043_009_0	4	1	Generic	1	2	010000		2	010100000010001000000110	30		90							2			90							30		31	14				5.00		15.00																								10.00																		5.00					5.00							
S0043	009	0		29	10	S0043_009_0	4	2	Preferred Brand	1	2	000001		2	110100000010001000000001	30		90							2			90							30				31	14		30.00		90.00																								60.00																		30.00								30.00				
S0043	009	0		29	10	S0043_009_0	4	3	Non-Preferred Brand	1	2	100000		2	110100000010001000000001	30		90							2			90							30				31	14		60.00		180.00																								120.00																		60.00								60.00				
S0043	009	0		29	10	S0043_009_0	4	4	Specialty Tier	1	2	001001		1	110100000010001000000111	30		90							2			90							30		31	14	31	14					120.00	25		25																							25																	25				25			25			
S0043	010	0		29	10	S0043_010_0	4	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							2			90							30				31	14		45.00		135.00																								90.00																		45.00								45.00				
S0043	010	0		29	10	S0043_010_0	4	4	Specialty Tier	1	4	001001	1	1	110100000010001000000111	30		90							2			90							30		31	14	31	14					120.00	25		25																							25																	25				25			25			
S0043	010	0		29	10	S0043_010_0	4	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		20.00		60.00																								40.00																		20.00								20.00				
S0043	010	0		29	10	S0043_010_0	4	1	Generic	1	4	010000	1	2	010100000010001000000110	30		90							2			90							30		31	14				4.00		12.00																								8.00																		4.00					4.00							
S0043	013	0		29	10	S0043_013_0	5	5	Specialty Tier	1	4	001001	1	1	110100000010001000000111	30		90							2			90							30		31	14	31	14					120.00	30		30																							30																	30				30			30			
S0043	013	0		29	10	S0043_013_0	5	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							2			90							30		31	14				2.00		6.00																								4.00																		2.00					2.00					2		
S0043	013	0		29	10	S0043_013_0	5	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				5.00		15.00																								10.00																		5.00					5.00					2		
S0043	013	0		29	10	S0043_013_0	5	4	Non-Preferred Brand	1	4	100000	3	2	110100000010001000000001	30		90							2			90							30				31	14		50.00		150.00																								100.00																		50.00								50.00				
S0043	013	0		29	10	S0043_013_0	5	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		25.00		75.00																								50.00																		25.00								25.00				
S0043	013	0		29	10	S0043_013_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							2			90							30		31	14				5.00		15.00																								10.00																		5.00					5.00							
S0043	013	0		29	10	S0043_013_0	5	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							2			90							30		31	14				2.00		6.00																								4.00																		2.00					2.00							
S0064	001	0		29	10	S0064_001_0	2	5	Specialty Tier	1	2	010010		1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	001	0		29	10	S0064_001_0	2	4	Non-Preferred Brand	1	2	100000		2	100010110110000000000001				30		90	30		90	1										30				31	1										62.00		155.00						95.00		237.50																										95.00								95.00				
S0064	001	0		29	10	S0064_001_0	2	3	Preferred Brand	1	2	010001		2	100010110110000000000101				30		90	30		90	1										30		31		31	1										25.00		62.50						45.00		112.50																										45.00					45.00			45.00				
S0064	001	0		29	10	S0064_001_0	2	2	Non-Preferred Generic	1	2	000100		2	000010110110000000000100				30		90	30		90	1										30		31													10.00		25.00						33.00		82.50																										33.00					33.00							
S0064	001	0		29	10	S0064_001_0	2	1	Preferred Generic	1	2	001000		2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	002	0		29	10	S0064_002_0	2	5	Specialty Tier	1	2	010010		1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	002	0		29	10	S0064_002_0	2	4	Non-Preferred Brand	1	2	100000		2	100010110110000000000001				30		90	30		90	1										30				31	1										85.00		212.50						95.00		237.50																										95.00								95.00				
S0064	002	0		29	10	S0064_002_0	2	3	Preferred Brand	1	2	010001		2	100010110110000000000101				30		90	30		90	1										30		31		31	1										35.00		87.50						45.00		112.50																										45.00					45.00			45.00				
S0064	002	0		29	10	S0064_002_0	2	1	Preferred Generic	1	2	001000		2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	002	0		29	10	S0064_002_0	2	2	Non-Preferred Generic	1	2	000100		2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	003	0		29	10	S0064_003_0	2	4	Non-Preferred Brand	1	2	100000		2	100010110110000000000001				30		90	30		90	1										30				31	1										85.00		212.50						95.00		237.50																										95.00								95.00				
S0064	003	0		29	10	S0064_003_0	2	3	Preferred Brand	1	2	010001		2	100010110110000000000101				30		90	30		90	1										30		31		31	1										35.00		87.50						45.00		112.50																										45.00					45.00			45.00				
S0064	003	0		29	10	S0064_003_0	2	2	Non-Preferred Generic	1	2	000100		2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	003	0		29	10	S0064_003_0	2	1	Preferred Generic	1	2	001000		2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	003	0		29	10	S0064_003_0	2	5	Specialty Tier	1	2	010010		1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	004	0		29	10	S0064_004_0	2	3	Preferred Brand	1	2	010001		2	100010110110000000000101				30		90	30		90	1										30		31		31	1										35.00		87.50						45.00		112.50																										45.00					45.00			45.00				
S0064	004	0		29	10	S0064_004_0	2	5	Specialty Tier	1	2	010010		1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	004	0		29	10	S0064_004_0	2	4	Non-Preferred Brand	1	2	100000		2	100010110110000000000001				30		90	30		90	1										30				31	1										81.00		202.50						95.00		237.50																										95.00								95.00				
S0064	004	0		29	10	S0064_004_0	2	2	Non-Preferred Generic	1	2	000100		2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	004	0		29	10	S0064_004_0	2	1	Preferred Generic	1	2	001000		2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	005	0		29	10	S0064_005_0	2	5	Specialty Tier	1	2	010010		1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	005	0		29	10	S0064_005_0	2	4	Non-Preferred Brand	1	2	100000		2	100010110110000000000001				30		90	30		90	1										30				31	1										81.00		202.50						95.00		237.50																										95.00								95.00				
S0064	005	0		29	10	S0064_005_0	2	3	Preferred Brand	1	2	010001		2	100010110110000000000101				30		90	30		90	1										30		31		31	1										35.00		87.50						45.00		112.50																										45.00					45.00			45.00				
S0064	005	0		29	10	S0064_005_0	2	2	Non-Preferred Generic	1	2	000100		2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	005	0		29	10	S0064_005_0	2	1	Preferred Generic	1	2	001000		2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	006	0		29	10	S0064_006_0	2	5	Specialty Tier	1	2	010010		1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	006	0		29	10	S0064_006_0	2	4	Non-Preferred Brand	1	2	100000		2	100010110110000000000001				30		90	30		90	1										30				31	1										85.00		212.50						95.00		237.50																										95.00								95.00				
S0064	006	0		29	10	S0064_006_0	2	3	Preferred Brand	1	2	010001		2	100010110110000000000101				30		90	30		90	1										30		31		31	1										31.00		77.50						45.00		112.50																										45.00					45.00			45.00				
S0064	006	0		29	10	S0064_006_0	2	2	Non-Preferred Generic	1	2	000100		2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	006	0		29	10	S0064_006_0	2	1	Preferred Generic	1	2	001000		2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	007	0		29	10	S0064_007_0	2	2	Non-Preferred Generic	1	2	000100		2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	007	0		29	10	S0064_007_0	2	1	Preferred Generic	1	2	001000		2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	007	0		29	10	S0064_007_0	2	3	Preferred Brand	1	2	010001		2	100010110110000000000101				30		90	30		90	1										30		31		31	1										31.00		77.50						45.00		112.50																										45.00					45.00			45.00				
S0064	007	0		29	10	S0064_007_0	2	4	Non-Preferred Brand	1	2	100000		2	100010110110000000000001				30		90	30		90	1										30				31	1										84.00		210.00						95.00		237.50																										95.00								95.00				
S0064	007	0		29	10	S0064_007_0	2	5	Specialty Tier	1	2	010010		1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	008	0		29	10	S0064_008_0	2	1	Preferred Generic	1	2	001000		2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	008	0		29	10	S0064_008_0	2	2	Non-Preferred Generic	1	2	000100		2	000010110110000000000100				30		90	30		90	1										30		31													21.00		52.50						33.00		82.50																										33.00					33.00							
S0064	008	0		29	10	S0064_008_0	2	3	Preferred Brand	1	2	010001		2	100010110110000000000101				30		90	30		90	1										30		31		31	1										35.00		87.50						45.00		112.50																										45.00					45.00			45.00				
S0064	008	0		29	10	S0064_008_0	2	4	Non-Preferred Brand	1	2	100000		2	100010110110000000000001				30		90	30		90	1										30				31	1										85.00		212.50						95.00		237.50																										95.00								95.00				
S0064	008	0		29	10	S0064_008_0	2	5	Specialty Tier	1	2	010010		1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	009	0		29	10	S0064_009_0	2	1	Preferred Generic	1	2	001000		2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	009	0		29	10	S0064_009_0	2	2	Non-Preferred Generic	1	2	000100		2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	009	0		29	10	S0064_009_0	2	5	Specialty Tier	1	2	010010		1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	009	0		29	10	S0064_009_0	2	3	Preferred Brand	1	2	010001		2	100010110110000000000101				30		90	30		90	1										30		31		31	1										33.00		82.50						45.00		112.50																										45.00					45.00			45.00				
S0064	009	0		29	10	S0064_009_0	2	4	Non-Preferred Brand	1	2	100000		2	100010110110000000000001				30		90	30		90	1										30				31	1										81.00		202.50						95.00		237.50																										95.00								95.00				
S0064	010	0		29	10	S0064_010_0	2	1	Preferred Generic	1	2	001000		2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	010	0		29	10	S0064_010_0	2	4	Non-Preferred Brand	1	2	100000		2	100010110110000000000001				30		90	30		90	1										30				31	1										80.00		200.00						95.00		237.50																										95.00								95.00				
S0064	010	0		29	10	S0064_010_0	2	3	Preferred Brand	1	2	010001		2	100010110110000000000101				30		90	30		90	1										30		31		31	1										35.00		87.50						45.00		112.50																										45.00					45.00			45.00				
S0064	010	0		29	10	S0064_010_0	2	2	Non-Preferred Generic	1	2	000100		2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	010	0		29	10	S0064_010_0	2	5	Specialty Tier	1	2	010010		1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	011	0		29	10	S0064_011_0	2	5	Specialty Tier	1	2	010010		1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	011	0		29	10	S0064_011_0	2	4	Non-Preferred Brand	1	2	100000		2	100010110110000000000001				30		90	30		90	1										30				31	1										85.00		212.50						95.00		237.50																										95.00								95.00				
S0064	011	0		29	10	S0064_011_0	2	3	Preferred Brand	1	2	010001		2	100010110110000000000101				30		90	30		90	1										30		31		31	1										35.00		87.50						45.00		112.50																										45.00					45.00			45.00				
S0064	011	0		29	10	S0064_011_0	2	2	Non-Preferred Generic	1	2	000100		2	000010110110000000000100				30		90	30		90	1										30		31													24.00		60.00						33.00		82.50																										33.00					33.00							
S0064	011	0		29	10	S0064_011_0	2	1	Preferred Generic	1	2	001000		2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	012	0		29	10	S0064_012_0	2	1	Preferred Generic	1	2	001000		2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	012	0		29	10	S0064_012_0	2	5	Specialty Tier	1	2	010010		1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	012	0		29	10	S0064_012_0	2	4	Non-Preferred Brand	1	2	100000		2	100010110110000000000001				30		90	30		90	1										30				31	1										85.00		212.50						95.00		237.50																										95.00								95.00				
S0064	012	0		29	10	S0064_012_0	2	3	Preferred Brand	1	2	010001		2	100010110110000000000101				30		90	30		90	1										30		31		31	1										34.00		85.00						45.00		112.50																										45.00					45.00			45.00				
S0064	012	0		29	10	S0064_012_0	2	2	Non-Preferred Generic	1	2	000100		2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	013	0		29	10	S0064_013_0	2	4	Non-Preferred Brand	1	2	100000		2	100010110110000000000001				30		90	30		90	1										30				31	1										85.00		212.50						95.00		237.50																										95.00								95.00				
S0064	013	0		29	10	S0064_013_0	2	3	Preferred Brand	1	2	010001		2	100010110110000000000101				30		90	30		90	1										30		31		31	1										33.00		82.50						45.00		112.50																										45.00					45.00			45.00				
S0064	013	0		29	10	S0064_013_0	2	2	Non-Preferred Generic	1	2	000100		2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	013	0		29	10	S0064_013_0	2	1	Preferred Generic	1	2	001000		2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	013	0		29	10	S0064_013_0	2	5	Specialty Tier	1	2	010010		1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	014	0		29	10	S0064_014_0	2	5	Specialty Tier	1	2	010010		1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	014	0		29	10	S0064_014_0	2	4	Non-Preferred Brand	1	2	100000		2	100010110110000000000001				30		90	30		90	1										30				31	1										85.00		212.50						95.00		237.50																										95.00								95.00				
S0064	014	0		29	10	S0064_014_0	2	3	Preferred Brand	1	2	010001		2	100010110110000000000101				30		90	30		90	1										30		31		31	1										32.00		80.00						45.00		112.50																										45.00					45.00			45.00				
S0064	014	0		29	10	S0064_014_0	2	2	Non-Preferred Generic	1	2	000100		2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	014	0		29	10	S0064_014_0	2	1	Preferred Generic	1	2	001000		2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	015	0		29	10	S0064_015_0	2	5	Specialty Tier	1	2	010010		1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	015	0		29	10	S0064_015_0	2	4	Non-Preferred Brand	1	2	100000		2	100010110110000000000001				30		90	30		90	1										30				31	1										85.00		212.50						95.00		237.50																										95.00								95.00				
S0064	015	0		29	10	S0064_015_0	2	3	Preferred Brand	1	2	010001		2	100010110110000000000101				30		90	30		90	1										30		31		31	1										32.00		80.00						45.00		112.50																										45.00					45.00			45.00				
S0064	015	0		29	10	S0064_015_0	2	2	Non-Preferred Generic	1	2	000100		2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	015	0		29	10	S0064_015_0	2	1	Preferred Generic	1	2	001000		2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	016	0		29	10	S0064_016_0	2	1	Preferred Generic	1	2	001000		2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	016	0		29	10	S0064_016_0	2	2	Non-Preferred Generic	1	2	000100		2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	016	0		29	10	S0064_016_0	2	3	Preferred Brand	1	2	010001		2	100010110110000000000101				30		90	30		90	1										30		31		31	1										34.00		85.00						45.00		112.50																										45.00					45.00			45.00				
S0064	016	0		29	10	S0064_016_0	2	4	Non-Preferred Brand	1	2	100000		2	100010110110000000000001				30		90	30		90	1										30				31	1										85.00		212.50						95.00		237.50																										95.00								95.00				
S0064	016	0		29	10	S0064_016_0	2	5	Specialty Tier	1	2	010010		1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	017	0		29	10	S0064_017_0	2	1	Preferred Generic	1	2	001000		2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	017	0		29	10	S0064_017_0	2	2	Non-Preferred Generic	1	2	000100		2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	017	0		29	10	S0064_017_0	2	3	Preferred Brand	1	2	010001		2	100010110110000000000101				30		90	30		90	1										30		31		31	1										33.00		82.50						45.00		112.50																										45.00					45.00			45.00				
S0064	017	0		29	10	S0064_017_0	2	4	Non-Preferred Brand	1	2	100000		2	100010110110000000000001				30		90	30		90	1										30				31	1										85.00		212.50						95.00		237.50																										95.00								95.00				
S0064	017	0		29	10	S0064_017_0	2	5	Specialty Tier	1	2	010010		1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	018	0		29	10	S0064_018_0	2	5	Specialty Tier	1	2	010010		1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	018	0		29	10	S0064_018_0	2	4	Non-Preferred Brand	1	2	100000		2	100010110110000000000001				30		90	30		90	1										30				31	1										85.00		212.50						95.00		237.50																										95.00								95.00				
S0064	018	0		29	10	S0064_018_0	2	3	Preferred Brand	1	2	010001		2	100010110110000000000101				30		90	30		90	1										30		31		31	1										32.00		80.00						45.00		112.50																										45.00					45.00			45.00				
S0064	018	0		29	10	S0064_018_0	2	1	Preferred Generic	1	2	001000		2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	018	0		29	10	S0064_018_0	2	2	Non-Preferred Generic	1	2	000100		2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	019	0		29	10	S0064_019_0	2	4	Non-Preferred Brand	1	2	100000		2	100010110110000000000001				30		90	30		90	1										30				31	1										77.00		192.50						95.00		237.50																										95.00								95.00				
S0064	019	0		29	10	S0064_019_0	2	3	Preferred Brand	1	2	010001		2	100010110110000000000101				30		90	30		90	1										30		31		31	1										30.00		75.00						45.00		112.50																										45.00					45.00			45.00				
S0064	019	0		29	10	S0064_019_0	2	2	Non-Preferred Generic	1	2	000100		2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	019	0		29	10	S0064_019_0	2	1	Preferred Generic	1	2	001000		2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	019	0		29	10	S0064_019_0	2	5	Specialty Tier	1	2	010010		1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	020	0		29	10	S0064_020_0	2	1	Preferred Generic	1	2	001000		2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	020	0		29	10	S0064_020_0	2	2	Non-Preferred Generic	1	2	000100		2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	020	0		29	10	S0064_020_0	2	3	Preferred Brand	1	2	010001		2	100010110110000000000101				30		90	30		90	1										30		31		31	1										30.00		75.00						45.00		112.50																										45.00					45.00			45.00				
S0064	020	0		29	10	S0064_020_0	2	5	Specialty Tier	1	2	010010		1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	020	0		29	10	S0064_020_0	2	4	Non-Preferred Brand	1	2	100000		2	100010110110000000000001				30		90	30		90	1										30				31	1										85.00		212.50						95.00		237.50																										95.00								95.00				
S0064	021	0		29	10	S0064_021_0	2	3	Preferred Brand	1	2	010001		2	100010110110000000000101				30		90	30		90	1										30		31		31	1										30.00		75.00						45.00		112.50																										45.00					45.00			45.00				
S0064	021	0		29	10	S0064_021_0	2	4	Non-Preferred Brand	1	2	100000		2	100010110110000000000001				30		90	30		90	1										30				31	1										77.00		192.50						95.00		237.50																										95.00								95.00				
S0064	021	0		29	10	S0064_021_0	2	2	Non-Preferred Generic	1	2	000100		2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	021	0		29	10	S0064_021_0	2	5	Specialty Tier	1	2	010010		1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	021	0		29	10	S0064_021_0	2	1	Preferred Generic	1	2	001000		2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	022	0		29	10	S0064_022_0	2	1	Preferred Generic	1	2	001000		2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	022	0		29	10	S0064_022_0	2	3	Preferred Brand	1	2	010001		2	100010110110000000000101				30		90	30		90	1										30		31		31	1										34.00		85.00						45.00		112.50																										45.00					45.00			45.00				
S0064	022	0		29	10	S0064_022_0	2	2	Non-Preferred Generic	1	2	000100		2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	022	0		29	10	S0064_022_0	2	4	Non-Preferred Brand	1	2	100000		2	100010110110000000000001				30		90	30		90	1										30				31	1										84.00		210.00						95.00		237.50																										95.00								95.00				
S0064	022	0		29	10	S0064_022_0	2	5	Specialty Tier	1	2	010010		1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	023	0		29	10	S0064_023_0	2	4	Non-Preferred Brand	1	2	100000		2	100010110110000000000001				30		90	30		90	1										30				31	1										85.00		212.50						95.00		237.50																										95.00								95.00				
S0064	023	0		29	10	S0064_023_0	2	2	Non-Preferred Generic	1	2	000100		2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	023	0		29	10	S0064_023_0	2	3	Preferred Brand	1	2	010001		2	100010110110000000000101				30		90	30		90	1										30		31		31	1										35.00		87.50						45.00		112.50																										45.00					45.00			45.00				
S0064	023	0		29	10	S0064_023_0	2	5	Specialty Tier	1	2	010010		1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	023	0		29	10	S0064_023_0	2	1	Preferred Generic	1	2	001000		2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	024	0		29	10	S0064_024_0	2	5	Specialty Tier	1	2	010010		1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	024	0		29	10	S0064_024_0	2	3	Preferred Brand	1	2	010001		2	100010110110000000000101				30		90	30		90	1										30		31		31	1										30.00		75.00						45.00		112.50																										45.00					45.00			45.00				
S0064	024	0		29	10	S0064_024_0	2	4	Non-Preferred Brand	1	2	100000		2	100010110110000000000001				30		90	30		90	1										30				31	1										80.00		200.00						95.00		237.50																										95.00								95.00				
S0064	024	0		29	10	S0064_024_0	2	2	Non-Preferred Generic	1	2	000100		2	000010110110000000000100				30		90	30		90	1										30		31													16.00		40.00						33.00		82.50																										33.00					33.00							
S0064	024	0		29	10	S0064_024_0	2	1	Preferred Generic	1	2	001000		2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	025	0		29	10	S0064_025_0	2	3	Preferred Brand	1	2	010001		2	100010110110000000000101				30		90	30		90	1										30		31		31	1										30.00		75.00						45.00		112.50																										45.00					45.00			45.00				
S0064	025	0		29	10	S0064_025_0	2	1	Preferred Generic	1	2	001000		2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	025	0		29	10	S0064_025_0	2	2	Non-Preferred Generic	1	2	000100		2	000010110110000000000100				30		90	30		90	1										30		31													15.00		37.50						33.00		82.50																										33.00					33.00							
S0064	025	0		29	10	S0064_025_0	2	4	Non-Preferred Brand	1	2	100000		2	100010110110000000000001				30		90	30		90	1										30				31	1										80.00		200.00						95.00		237.50																										95.00								95.00				
S0064	025	0		29	10	S0064_025_0	2	5	Specialty Tier	1	2	010010		1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	026	0		29	10	S0064_026_0	2	5	Specialty Tier	1	2	010010		1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	026	0		29	10	S0064_026_0	2	4	Non-Preferred Brand	1	2	100000		2	100010110110000000000001				30		90	30		90	1										30				31	1										81.00		202.50						95.00		237.50																										95.00								95.00				
S0064	026	0		29	10	S0064_026_0	2	3	Preferred Brand	1	2	010001		2	100010110110000000000101				30		90	30		90	1										30		31		31	1										32.00		80.00						45.00		112.50																										45.00					45.00			45.00				
S0064	026	0		29	10	S0064_026_0	2	1	Preferred Generic	1	2	001000		2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	026	0		29	10	S0064_026_0	2	2	Non-Preferred Generic	1	2	000100		2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	027	0		29	10	S0064_027_0	2	5	Specialty Tier	1	2	010010		1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	027	0		29	10	S0064_027_0	2	4	Non-Preferred Brand	1	2	100000		2	100010110110000000000001				30		90	30		90	1										30				31	1										85.00		212.50						95.00		237.50																										95.00								95.00				
S0064	027	0		29	10	S0064_027_0	2	3	Preferred Brand	1	2	010001		2	100010110110000000000101				30		90	30		90	1										30		31		31	1										31.00		77.50						45.00		112.50																										45.00					45.00			45.00				
S0064	027	0		29	10	S0064_027_0	2	1	Preferred Generic	1	2	001000		2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	027	0		29	10	S0064_027_0	2	2	Non-Preferred Generic	1	2	000100		2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	028	0		29	10	S0064_028_0	2	5	Specialty Tier	1	2	010010		1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	028	0		29	10	S0064_028_0	2	1	Preferred Generic	1	2	001000		2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	028	0		29	10	S0064_028_0	2	2	Non-Preferred Generic	1	2	000100		2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	028	0		29	10	S0064_028_0	2	3	Preferred Brand	1	2	010001		2	100010110110000000000101				30		90	30		90	1										30		31		31	1										32.00		80.00						45.00		112.50																										45.00					45.00			45.00				
S0064	028	0		29	10	S0064_028_0	2	4	Non-Preferred Brand	1	2	100000		2	100010110110000000000001				30		90	30		90	1										30				31	1										79.00		197.50						95.00		237.50																										95.00								95.00				
S0064	029	0		29	10	S0064_029_0	2	5	Specialty Tier	1	2	010010		1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	029	0		29	10	S0064_029_0	2	1	Preferred Generic	1	2	001000		2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	029	0		29	10	S0064_029_0	2	2	Non-Preferred Generic	1	2	000100		2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	029	0		29	10	S0064_029_0	2	3	Preferred Brand	1	2	010001		2	100010110110000000000101				30		90	30		90	1										30		31		31	1										33.00		82.50						45.00		112.50																										45.00					45.00			45.00				
S0064	029	0		29	10	S0064_029_0	2	4	Non-Preferred Brand	1	2	100000		2	100010110110000000000001				30		90	30		90	1										30				31	1										85.00		212.50						95.00		237.50																										95.00								95.00				
S0064	030	0		29	10	S0064_030_0	2	2	Non-Preferred Generic	1	2	000100		2	000010110110000000000100				30		90	30		90	1										30		31													17.00		42.50						33.00		82.50																										33.00					33.00							
S0064	030	0		29	10	S0064_030_0	2	1	Preferred Generic	1	2	001000		2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	030	0		29	10	S0064_030_0	2	5	Specialty Tier	1	2	010010		1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	030	0		29	10	S0064_030_0	2	4	Non-Preferred Brand	1	2	100000		2	100010110110000000000001				30		90	30		90	1										30				31	1										80.00		200.00						95.00		237.50																										95.00								95.00				
S0064	030	0		29	10	S0064_030_0	2	3	Preferred Brand	1	2	010001		2	100010110110000000000101				30		90	30		90	1										30		31		31	1										30.00		75.00						45.00		112.50																										45.00					45.00			45.00				
S0064	031	0		29	10	S0064_031_0	2	3	Preferred Brand	1	2	010001		2	100010110110000000000101				30		90	30		90	1										30		31		31	1										30.00		75.00						45.00		112.50																										45.00					45.00			45.00				
S0064	031	0		29	10	S0064_031_0	2	5	Specialty Tier	1	2	010010		1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	031	0		29	10	S0064_031_0	2	4	Non-Preferred Brand	1	2	100000		2	100010110110000000000001				30		90	30		90	1										30				31	1										85.00		212.50						95.00		237.50																										95.00								95.00				
S0064	031	0		29	10	S0064_031_0	2	2	Non-Preferred Generic	1	2	000100		2	000010110110000000000100				30		90	30		90	1										30		31													21.00		52.50						33.00		82.50																										33.00					33.00							
S0064	031	0		29	10	S0064_031_0	2	1	Preferred Generic	1	2	001000		2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	032	0		29	10	S0064_032_0	2	3	Preferred Brand	1	2	010001		2	100010110110000000000101				30		90	30		90	1										30		31		31	1										32.00		80.00						45.00		112.50																										45.00					45.00			45.00				
S0064	032	0		29	10	S0064_032_0	2	4	Non-Preferred Brand	1	2	100000		2	100010110110000000000001				30		90	30		90	1										30				31	1										85.00		212.50						95.00		237.50																										95.00								95.00				
S0064	032	0		29	10	S0064_032_0	2	5	Specialty Tier	1	2	010010		1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	032	0		29	10	S0064_032_0	2	2	Non-Preferred Generic	1	2	000100		2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	032	0		29	10	S0064_032_0	2	1	Preferred Generic	1	2	001000		2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	033	0		29	10	S0064_033_0	2	4	Non-Preferred Brand	1	2	100000		2	100010110110000000000001				30		90	30		90	1										30				31	1										85.00		212.50						95.00		237.50																										95.00								95.00				
S0064	033	0		29	10	S0064_033_0	2	5	Specialty Tier	1	2	010010		1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	033	0		29	10	S0064_033_0	2	3	Preferred Brand	1	2	010001		2	100010110110000000000101				30		90	30		90	1										30		31		31	1										30.00		75.00						45.00		112.50																										45.00					45.00			45.00				
S0064	033	0		29	10	S0064_033_0	2	2	Non-Preferred Generic	1	2	000100		2	000010110110000000000100				30		90	30		90	1										30		31													21.00		52.50						33.00		82.50																										33.00					33.00							
S0064	033	0		29	10	S0064_033_0	2	1	Preferred Generic	1	2	001000		2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	034	0		29	10	S0064_034_0	2	2	Non-Preferred Generic	1	2	000100		2	000010110110000000000100				30		90	30		90	1										30		31													10.00		25.00						20.00		50.00																										20.00					20.00							
S0064	034	0		29	10	S0064_034_0	2	1	Preferred Generic	1	2	001000		2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	034	0		29	10	S0064_034_0	2	3	Preferred Brand	1	2	010001		2	100010110110000000000101				30		90	30		90	1										30		31		31	1										25.00		62.50						35.00		87.50																										35.00					35.00			35.00				
S0064	034	0		29	10	S0064_034_0	2	4	Non-Preferred Brand	1	2	100000		2	100010110110000000000001				30		90	30		90	1										30				31	1										55.00		137.50						65.00		162.50																										65.00								65.00				
S0064	034	0		29	10	S0064_034_0	2	5	Specialty Tier	1	2	010010		1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	035	0		29	10	S0064_035_0	2	1	Preferred Generic	1	2	001000		2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	035	0		29	10	S0064_035_0	2	2	Non-Preferred Generic	1	2	000100		2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	035	0		29	10	S0064_035_0	2	3	Preferred Brand	1	2	010001		2	100010110110000000000101				30		90	30		90	1										30		31		31	1										35.00		87.50						45.00		112.50																										45.00					45.00			45.00				
S0064	035	0		29	10	S0064_035_0	2	4	Non-Preferred Brand	1	2	100000		2	100010110110000000000001				30		90	30		90	1										30				31	1										82.00		205.00						95.00		237.50																										95.00								95.00				
S0064	035	0		29	10	S0064_035_0	2	5	Specialty Tier	1	2	010010		1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	036	0		29	10	S0064_036_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	036	0		29	10	S0064_036_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	036	0		29	10	S0064_036_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110000000000101				30		90	30		90	1										30		31		31	1										25.00		62.50						45.00		112.50																										45.00					45.00			45.00				
S0064	036	0		29	10	S0064_036_0	2	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000000000100				30		90	30		90	1										30		31													10.00		25.00						33.00		82.50																										33.00					33.00							
S0064	036	0		29	10	S0064_036_0	2	4	Non-Preferred Brand	1	4	100000	1	2	100010110110000000000001				30		90	30		90	1										30				31	1										62.00		155.00						95.00		237.50																										95.00								95.00				
S0064	036	0		29	10	S0064_036_0	2	1	Preferred Generic	3	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00					1		
S0064	037	0		29	10	S0064_037_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	037	0		29	10	S0064_037_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	037	0		29	10	S0064_037_0	2	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	037	0		29	10	S0064_037_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110000000000101				30		90	30		90	1										30		31		31	1										35.00		87.50						45.00		112.50																										45.00					45.00			45.00				
S0064	037	0		29	10	S0064_037_0	2	4	Non-Preferred Brand	1	4	100000	1	2	100010110110000000000001				30		90	30		90	1										30				31	1										85.00		212.50						95.00		237.50																										95.00								95.00				
S0064	037	0		29	10	S0064_037_0	2	1	Preferred Generic	3	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00					1		
S0064	038	0		29	10	S0064_038_0	2	1	Preferred Generic	3	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00					1		
S0064	038	0		29	10	S0064_038_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	038	0		29	10	S0064_038_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	038	0		29	10	S0064_038_0	2	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	038	0		29	10	S0064_038_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110000000000101				30		90	30		90	1										30		31		31	1										35.00		87.50						45.00		112.50																										45.00					45.00			45.00				
S0064	038	0		29	10	S0064_038_0	2	4	Non-Preferred Brand	1	4	100000	1	2	100010110110000000000001				30		90	30		90	1										30				31	1										85.00		212.50						95.00		237.50																										95.00								95.00				
S0064	039	0		29	10	S0064_039_0	2	1	Preferred Generic	3	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00					1		
S0064	039	0		29	10	S0064_039_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	039	0		29	10	S0064_039_0	2	4	Non-Preferred Brand	1	4	100000	1	2	100010110110000000000001				30		90	30		90	1										30				31	1										81.00		202.50						95.00		237.50																										95.00								95.00				
S0064	039	0		29	10	S0064_039_0	2	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	039	0		29	10	S0064_039_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110000000000101				30		90	30		90	1										30		31		31	1										35.00		87.50						45.00		112.50																										45.00					45.00			45.00				
S0064	039	0		29	10	S0064_039_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	040	0		29	10	S0064_040_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	040	0		29	10	S0064_040_0	2	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	040	0		29	10	S0064_040_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110000000000101				30		90	30		90	1										30		31		31	1										35.00		87.50						45.00		112.50																										45.00					45.00			45.00				
S0064	040	0		29	10	S0064_040_0	2	4	Non-Preferred Brand	1	4	100000	1	2	100010110110000000000001				30		90	30		90	1										30				31	1										81.00		202.50						95.00		237.50																										95.00								95.00				
S0064	040	0		29	10	S0064_040_0	2	1	Preferred Generic	3	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00					1		
S0064	040	0		29	10	S0064_040_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	041	0		29	10	S0064_041_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	041	0		29	10	S0064_041_0	2	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	041	0		29	10	S0064_041_0	2	1	Preferred Generic	3	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00					1		
S0064	041	0		29	10	S0064_041_0	2	4	Non-Preferred Brand	1	4	100000	1	2	100010110110000000000001				30		90	30		90	1										30				31	1										85.00		212.50						95.00		237.50																										95.00								95.00				
S0064	041	0		29	10	S0064_041_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110000000000101				30		90	30		90	1										30		31		31	1										31.00		77.50						45.00		112.50																										45.00					45.00			45.00				
S0064	041	0		29	10	S0064_041_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	042	0		29	10	S0064_042_0	2	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	042	0		29	10	S0064_042_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110000000000101				30		90	30		90	1										30		31		31	1										31.00		77.50						45.00		112.50																										45.00					45.00			45.00				
S0064	042	0		29	10	S0064_042_0	2	4	Non-Preferred Brand	1	4	100000	1	2	100010110110000000000001				30		90	30		90	1										30				31	1										84.00		210.00						95.00		237.50																										95.00								95.00				
S0064	042	0		29	10	S0064_042_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	042	0		29	10	S0064_042_0	2	1	Preferred Generic	3	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00					1		
S0064	042	0		29	10	S0064_042_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	043	0		29	10	S0064_043_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	043	0		29	10	S0064_043_0	2	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000000000100				30		90	30		90	1										30		31													21.00		52.50						33.00		82.50																										33.00					33.00							
S0064	043	0		29	10	S0064_043_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110000000000101				30		90	30		90	1										30		31		31	1										35.00		87.50						45.00		112.50																										45.00					45.00			45.00				
S0064	043	0		29	10	S0064_043_0	2	4	Non-Preferred Brand	1	4	100000	1	2	100010110110000000000001				30		90	30		90	1										30				31	1										85.00		212.50						95.00		237.50																										95.00								95.00				
S0064	043	0		29	10	S0064_043_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	043	0		29	10	S0064_043_0	2	1	Preferred Generic	3	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00					1		
S0064	044	0		29	10	S0064_044_0	2	1	Preferred Generic	3	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00					1		
S0064	044	0		29	10	S0064_044_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	044	0		29	10	S0064_044_0	2	4	Non-Preferred Brand	1	4	100000	1	2	100010110110000000000001				30		90	30		90	1										30				31	1										81.00		202.50						95.00		237.50																										95.00								95.00				
S0064	044	0		29	10	S0064_044_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110000000000101				30		90	30		90	1										30		31		31	1										33.00		82.50						45.00		112.50																										45.00					45.00			45.00				
S0064	044	0		29	10	S0064_044_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	044	0		29	10	S0064_044_0	2	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	045	0		29	10	S0064_045_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	045	0		29	10	S0064_045_0	2	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	045	0		29	10	S0064_045_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110000000000101				30		90	30		90	1										30		31		31	1										35.00		87.50						45.00		112.50																										45.00					45.00			45.00				
S0064	045	0		29	10	S0064_045_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	045	0		29	10	S0064_045_0	2	4	Non-Preferred Brand	1	4	100000	1	2	100010110110000000000001				30		90	30		90	1										30				31	1										80.00		200.00						95.00		237.50																										95.00								95.00				
S0064	045	0		29	10	S0064_045_0	2	1	Preferred Generic	3	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00					1		
S0064	046	0		29	10	S0064_046_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110000000000101				30		90	30		90	1										30		31		31	1										35.00		87.50						45.00		112.50																										45.00					45.00			45.00				
S0064	046	0		29	10	S0064_046_0	2	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000000000100				30		90	30		90	1										30		31													24.00		60.00						33.00		82.50																										33.00					33.00							
S0064	046	0		29	10	S0064_046_0	2	1	Preferred Generic	3	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00					1		
S0064	046	0		29	10	S0064_046_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	046	0		29	10	S0064_046_0	2	4	Non-Preferred Brand	1	4	100000	1	2	100010110110000000000001				30		90	30		90	1										30				31	1										85.00		212.50						95.00		237.50																										95.00								95.00				
S0064	046	0		29	10	S0064_046_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	047	0		29	10	S0064_047_0	2	1	Preferred Generic	3	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00					1		
S0064	047	0		29	10	S0064_047_0	2	4	Non-Preferred Brand	1	4	100000	1	2	100010110110000000000001				30		90	30		90	1										30				31	1										85.00		212.50						95.00		237.50																										95.00								95.00				
S0064	047	0		29	10	S0064_047_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110000000000101				30		90	30		90	1										30		31		31	1										34.00		85.00						45.00		112.50																										45.00					45.00			45.00				
S0064	047	0		29	10	S0064_047_0	2	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	047	0		29	10	S0064_047_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	047	0		29	10	S0064_047_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	048	0		29	10	S0064_048_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	048	0		29	10	S0064_048_0	2	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	048	0		29	10	S0064_048_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110000000000101				30		90	30		90	1										30		31		31	1										33.00		82.50						45.00		112.50																										45.00					45.00			45.00				
S0064	048	0		29	10	S0064_048_0	2	4	Non-Preferred Brand	1	4	100000	1	2	100010110110000000000001				30		90	30		90	1										30				31	1										85.00		212.50						95.00		237.50																										95.00								95.00				
S0064	048	0		29	10	S0064_048_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	048	0		29	10	S0064_048_0	2	1	Preferred Generic	3	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00					1		
S0064	049	0		29	10	S0064_049_0	2	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	049	0		29	10	S0064_049_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	049	0		29	10	S0064_049_0	2	1	Preferred Generic	3	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00					1		
S0064	049	0		29	10	S0064_049_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	049	0		29	10	S0064_049_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110000000000101				30		90	30		90	1										30		31		31	1										32.00		80.00						45.00		112.50																										45.00					45.00			45.00				
S0064	049	0		29	10	S0064_049_0	2	4	Non-Preferred Brand	1	4	100000	1	2	100010110110000000000001				30		90	30		90	1										30				31	1										85.00		212.50						95.00		237.50																										95.00								95.00				
S0064	050	0		29	10	S0064_050_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	050	0		29	10	S0064_050_0	2	4	Non-Preferred Brand	1	4	100000	1	2	100010110110000000000001				30		90	30		90	1										30				31	1										85.00		212.50						95.00		237.50																										95.00								95.00				
S0064	050	0		29	10	S0064_050_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110000000000101				30		90	30		90	1										30		31		31	1										32.00		80.00						45.00		112.50																										45.00					45.00			45.00				
S0064	050	0		29	10	S0064_050_0	2	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	050	0		29	10	S0064_050_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	050	0		29	10	S0064_050_0	2	1	Preferred Generic	3	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00					1		
S0064	051	0		29	10	S0064_051_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	051	0		29	10	S0064_051_0	2	4	Non-Preferred Brand	1	4	100000	1	2	100010110110000000000001				30		90	30		90	1										30				31	1										85.00		212.50						95.00		237.50																										95.00								95.00				
S0064	051	0		29	10	S0064_051_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110000000000101				30		90	30		90	1										30		31		31	1										34.00		85.00						45.00		112.50																										45.00					45.00			45.00				
S0064	051	0		29	10	S0064_051_0	2	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	051	0		29	10	S0064_051_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	051	0		29	10	S0064_051_0	2	1	Preferred Generic	3	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00					1		
S0064	052	0		29	10	S0064_052_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	052	0		29	10	S0064_052_0	2	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	052	0		29	10	S0064_052_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110000000000101				30		90	30		90	1										30		31		31	1										33.00		82.50						45.00		112.50																										45.00					45.00			45.00				
S0064	052	0		29	10	S0064_052_0	2	4	Non-Preferred Brand	1	4	100000	1	2	100010110110000000000001				30		90	30		90	1										30				31	1										85.00		212.50						95.00		237.50																										95.00								95.00				
S0064	052	0		29	10	S0064_052_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	052	0		29	10	S0064_052_0	2	1	Preferred Generic	3	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00					1		
S0064	053	0		29	10	S0064_053_0	2	1	Preferred Generic	3	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00					1		
S0064	053	0		29	10	S0064_053_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	053	0		29	10	S0064_053_0	2	4	Non-Preferred Brand	1	4	100000	1	2	100010110110000000000001				30		90	30		90	1										30				31	1										85.00		212.50						95.00		237.50																										95.00								95.00				
S0064	053	0		29	10	S0064_053_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110000000000101				30		90	30		90	1										30		31		31	1										32.00		80.00						45.00		112.50																										45.00					45.00			45.00				
S0064	053	0		29	10	S0064_053_0	2	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	053	0		29	10	S0064_053_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	054	0		29	10	S0064_054_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	054	0		29	10	S0064_054_0	2	1	Preferred Generic	3	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00					1		
S0064	054	0		29	10	S0064_054_0	2	4	Non-Preferred Brand	1	4	100000	1	2	100010110110000000000001				30		90	30		90	1										30				31	1										77.00		192.50						95.00		237.50																										95.00								95.00				
S0064	054	0		29	10	S0064_054_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110000000000101				30		90	30		90	1										30		31		31	1										30.00		75.00						45.00		112.50																										45.00					45.00			45.00				
S0064	054	0		29	10	S0064_054_0	2	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	054	0		29	10	S0064_054_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	055	0		29	10	S0064_055_0	2	1	Preferred Generic	3	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00					1		
S0064	055	0		29	10	S0064_055_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	055	0		29	10	S0064_055_0	2	4	Non-Preferred Brand	1	4	100000	1	2	100010110110000000000001				30		90	30		90	1										30				31	1										85.00		212.50						95.00		237.50																										95.00								95.00				
S0064	055	0		29	10	S0064_055_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110000000000101				30		90	30		90	1										30		31		31	1										30.00		75.00						45.00		112.50																										45.00					45.00			45.00				
S0064	055	0		29	10	S0064_055_0	2	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	055	0		29	10	S0064_055_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	056	0		29	10	S0064_056_0	2	1	Preferred Generic	3	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00					1		
S0064	056	0		29	10	S0064_056_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	056	0		29	10	S0064_056_0	2	4	Non-Preferred Brand	1	4	100000	1	2	100010110110000000000001				30		90	30		90	1										30				31	1										77.00		192.50						95.00		237.50																										95.00								95.00				
S0064	056	0		29	10	S0064_056_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110000000000101				30		90	30		90	1										30		31		31	1										30.00		75.00						45.00		112.50																										45.00					45.00			45.00				
S0064	056	0		29	10	S0064_056_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	056	0		29	10	S0064_056_0	2	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	057	0		29	10	S0064_057_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	057	0		29	10	S0064_057_0	2	4	Non-Preferred Brand	1	4	100000	1	2	100010110110000000000001				30		90	30		90	1										30				31	1										84.00		210.00						95.00		237.50																										95.00								95.00				
S0064	057	0		29	10	S0064_057_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110000000000101				30		90	30		90	1										30		31		31	1										34.00		85.00						45.00		112.50																										45.00					45.00			45.00				
S0064	057	0		29	10	S0064_057_0	2	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	057	0		29	10	S0064_057_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	057	0		29	10	S0064_057_0	2	1	Preferred Generic	3	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00					1		
S0064	058	0		29	10	S0064_058_0	2	1	Preferred Generic	3	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00					1		
S0064	058	0		29	10	S0064_058_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	058	0		29	10	S0064_058_0	2	4	Non-Preferred Brand	1	4	100000	1	2	100010110110000000000001				30		90	30		90	1										30				31	1										85.00		212.50						95.00		237.50																										95.00								95.00				
S0064	058	0		29	10	S0064_058_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110000000000101				30		90	30		90	1										30		31		31	1										35.00		87.50						45.00		112.50																										45.00					45.00			45.00				
S0064	058	0		29	10	S0064_058_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	058	0		29	10	S0064_058_0	2	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	059	0		29	10	S0064_059_0	2	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000000000100				30		90	30		90	1										30		31													16.00		40.00						33.00		82.50																										33.00					33.00							
S0064	059	0		29	10	S0064_059_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110000000000101				30		90	30		90	1										30		31		31	1										30.00		75.00						45.00		112.50																										45.00					45.00			45.00				
S0064	059	0		29	10	S0064_059_0	2	4	Non-Preferred Brand	1	4	100000	1	2	100010110110000000000001				30		90	30		90	1										30				31	1										80.00		200.00						95.00		237.50																										95.00								95.00				
S0064	059	0		29	10	S0064_059_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	059	0		29	10	S0064_059_0	2	1	Preferred Generic	3	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00					1		
S0064	059	0		29	10	S0064_059_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	060	0		29	10	S0064_060_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	060	0		29	10	S0064_060_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	060	0		29	10	S0064_060_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110000000000101				30		90	30		90	1										30		31		31	1										30.00		75.00						45.00		112.50																										45.00					45.00			45.00				
S0064	060	0		29	10	S0064_060_0	2	4	Non-Preferred Brand	1	4	100000	1	2	100010110110000000000001				30		90	30		90	1										30				31	1										80.00		200.00						95.00		237.50																										95.00								95.00				
S0064	060	0		29	10	S0064_060_0	2	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000000000100				30		90	30		90	1										30		31													15.00		37.50						33.00		82.50																										33.00					33.00							
S0064	060	0		29	10	S0064_060_0	2	1	Preferred Generic	3	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00					1		
S0064	061	0		29	10	S0064_061_0	2	1	Preferred Generic	3	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00					1		
S0064	061	0		29	10	S0064_061_0	2	4	Non-Preferred Brand	1	4	100000	1	2	100010110110000000000001				30		90	30		90	1										30				31	1										81.00		202.50						95.00		237.50																										95.00								95.00				
S0064	061	0		29	10	S0064_061_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110000000000101				30		90	30		90	1										30		31		31	1										32.00		80.00						45.00		112.50																										45.00					45.00			45.00				
S0064	061	0		29	10	S0064_061_0	2	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	061	0		29	10	S0064_061_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	061	0		29	10	S0064_061_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	062	0		29	10	S0064_062_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	062	0		29	10	S0064_062_0	2	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	062	0		29	10	S0064_062_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110000000000101				30		90	30		90	1										30		31		31	1										31.00		77.50						45.00		112.50																										45.00					45.00			45.00				
S0064	062	0		29	10	S0064_062_0	2	4	Non-Preferred Brand	1	4	100000	1	2	100010110110000000000001				30		90	30		90	1										30				31	1										85.00		212.50						95.00		237.50																										95.00								95.00				
S0064	062	0		29	10	S0064_062_0	2	1	Preferred Generic	3	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00					1		
S0064	062	0		29	10	S0064_062_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	063	0		29	10	S0064_063_0	2	1	Preferred Generic	3	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00					1		
S0064	063	0		29	10	S0064_063_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	063	0		29	10	S0064_063_0	2	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	063	0		29	10	S0064_063_0	2	4	Non-Preferred Brand	1	4	100000	1	2	100010110110000000000001				30		90	30		90	1										30				31	1										79.00		197.50						95.00		237.50																										95.00								95.00				
S0064	063	0		29	10	S0064_063_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	063	0		29	10	S0064_063_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110000000000101				30		90	30		90	1										30		31		31	1										32.00		80.00						45.00		112.50																										45.00					45.00			45.00				
S0064	064	0		29	10	S0064_064_0	2	1	Preferred Generic	3	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00					1		
S0064	064	0		29	10	S0064_064_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	064	0		29	10	S0064_064_0	2	4	Non-Preferred Brand	1	4	100000	1	2	100010110110000000000001				30		90	30		90	1										30				31	1										85.00		212.50						95.00		237.50																										95.00								95.00				
S0064	064	0		29	10	S0064_064_0	2	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	064	0		29	10	S0064_064_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110000000000101				30		90	30		90	1										30		31		31	1										33.00		82.50						45.00		112.50																										45.00					45.00			45.00				
S0064	064	0		29	10	S0064_064_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	065	0		29	10	S0064_065_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	065	0		29	10	S0064_065_0	2	1	Preferred Generic	3	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00					1		
S0064	065	0		29	10	S0064_065_0	2	4	Non-Preferred Brand	1	4	100000	1	2	100010110110000000000001				30		90	30		90	1										30				31	1										80.00		200.00						95.00		237.50																										95.00								95.00				
S0064	065	0		29	10	S0064_065_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110000000000101				30		90	30		90	1										30		31		31	1										30.00		75.00						45.00		112.50																										45.00					45.00			45.00				
S0064	065	0		29	10	S0064_065_0	2	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000000000100				30		90	30		90	1										30		31													17.00		42.50						33.00		82.50																										33.00					33.00							
S0064	065	0		29	10	S0064_065_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	066	0		29	10	S0064_066_0	2	1	Preferred Generic	3	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00					1		
S0064	066	0		29	10	S0064_066_0	2	4	Non-Preferred Brand	1	4	100000	1	2	100010110110000000000001				30		90	30		90	1										30				31	1										85.00		212.50						95.00		237.50																										95.00								95.00				
S0064	066	0		29	10	S0064_066_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	066	0		29	10	S0064_066_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	066	0		29	10	S0064_066_0	2	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000000000100				30		90	30		90	1										30		31													21.00		52.50						33.00		82.50																										33.00					33.00							
S0064	066	0		29	10	S0064_066_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110000000000101				30		90	30		90	1										30		31		31	1										30.00		75.00						45.00		112.50																										45.00					45.00			45.00				
S0064	067	0		29	10	S0064_067_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	067	0		29	10	S0064_067_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110000000000101				30		90	30		90	1										30		31		31	1										32.00		80.00						45.00		112.50																										45.00					45.00			45.00				
S0064	067	0		29	10	S0064_067_0	2	4	Non-Preferred Brand	1	4	100000	1	2	100010110110000000000001				30		90	30		90	1										30				31	1										85.00		212.50						95.00		237.50																										95.00								95.00				
S0064	067	0		29	10	S0064_067_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	067	0		29	10	S0064_067_0	2	1	Preferred Generic	3	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00					1		
S0064	067	0		29	10	S0064_067_0	2	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	068	0		29	10	S0064_068_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	068	0		29	10	S0064_068_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	068	0		29	10	S0064_068_0	2	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000000000100				30		90	30		90	1										30		31													21.00		52.50						33.00		82.50																										33.00					33.00							
S0064	068	0		29	10	S0064_068_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110000000000101				30		90	30		90	1										30		31		31	1										30.00		75.00						45.00		112.50																										45.00					45.00			45.00				
S0064	068	0		29	10	S0064_068_0	2	4	Non-Preferred Brand	1	4	100000	1	2	100010110110000000000001				30		90	30		90	1										30				31	1										85.00		212.50						95.00		237.50																										95.00								95.00				
S0064	068	0		29	10	S0064_068_0	2	1	Preferred Generic	3	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00					1		
S0064	069	0		29	10	S0064_069_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	069	0		29	10	S0064_069_0	2	1	Preferred Generic	3	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00					1		
S0064	069	0		29	10	S0064_069_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	069	0		29	10	S0064_069_0	2	4	Non-Preferred Brand	1	4	100000	1	2	100010110110000000000001				30		90	30		90	1										30				31	1										55.00		137.50						65.00		162.50																										65.00								65.00				
S0064	069	0		29	10	S0064_069_0	2	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000000000100				30		90	30		90	1										30		31													10.00		25.00						20.00		50.00																										20.00					20.00							
S0064	069	0		29	10	S0064_069_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110000000000101				30		90	30		90	1										30		31		31	1										25.00		62.50						35.00		87.50																										35.00					35.00			35.00				
S0064	070	0		29	10	S0064_070_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00							
S0064	070	0		29	10	S0064_070_0	2	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000000000100				30		90	30		90	1										30		31													20.00		50.00						33.00		82.50																										33.00					33.00							
S0064	070	0		29	10	S0064_070_0	2	1	Preferred Generic	3	4	001000	1	2	000010110110000000000100				30		90	30		90	1										30		31													0.00		0.00						10.00		25.00																										10.00					10.00					1		
S0064	070	0		29	10	S0064_070_0	2	4	Non-Preferred Brand	1	4	100000	1	2	100010110110000000000001				30		90	30		90	1										30				31	1										82.00		205.00						95.00		237.50																										95.00								95.00				
S0064	070	0		29	10	S0064_070_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110000000000101				30		90	30		90	1										30		31		31	1													25.00	25		25					25.00	25		25																								25				25			25			
S0064	070	0		29	10	S0064_070_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110000000000101				30		90	30		90	1										30		31		31	1										35.00		87.50						45.00		112.50																										45.00					45.00			45.00				
S0128	003	0		29	10	S0128_003_0	6	3	Preferred Brand	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	1.17	35.00		105.00																					1.17	35.00		105.00																		35.00				1.13	35.00		1.13	35.00				
S0128	003	0		29	10	S0128_003_0	6	1	Preferred Generic	1	2	001010		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.03	1.00		3.00																					0.03	1.00		3.00																		1.00				0.03	1.00		0.03	1.00				
S0128	003	0		29	10	S0128_003_0	6	2	Non-Preferred Generic	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.08	2.50		7.50																					0.08	2.50		7.50																		2.50				0.08	2.50		0.08	2.50				
S0128	003	0		29	10	S0128_003_0	6	4	Non-Preferred Brand	1	2	110000		1	110100000010101000000111	30		90							2	30		90							30		31	14	31	14					88.75	27		27																					27		27																	27				27			27			
S0128	004	0		29	10	S0128_004_0	4	4	Non-Preferred Brand	1	2	110000		1	110100000010101000000111	30		90							2	30		90							30		31	14	31	14					92.74	27		27																					27		27																	27				27			27			
S0128	004	0		29	10	S0128_004_0	4	2	Non-Preferred Generic	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.08	2.50		7.50																					0.08	2.50		7.50																		2.50				0.08	2.50		0.08	2.50				
S0128	004	0		29	10	S0128_004_0	4	1	Preferred Generic	1	2	001010		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.03	1.00		3.00																					0.03	1.00		3.00																		1.00				0.03	1.00		0.03	1.00				
S0128	004	0		29	10	S0128_004_0	4	3	Preferred Brand	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	1.23	37.00		111.00																					1.23	37.00		111.00																		37.00				1.19	37.00		1.19	37.00				
S0128	005	0		29	10	S0128_005_0	4	4	Non-Preferred Brand	1	2	110000		1	110100000010101000000111	30		90							2	30		90							30		31	14	31	14					92.91	27		27																					27		27																	27				27			27			
S0128	005	0		29	10	S0128_005_0	4	1	Preferred Generic	1	2	001010		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.03	1.00		3.00																					0.03	1.00		3.00																		1.00				0.03	1.00		0.03	1.00				
S0128	005	0		29	10	S0128_005_0	4	2	Non-Preferred Generic	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.08	2.50		7.50																					0.08	2.50		7.50																		2.50				0.08	2.50		0.08	2.50				
S0128	005	0		29	10	S0128_005_0	4	3	Preferred Brand	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	1.23	37.00		111.00																					1.23	37.00		111.00																		37.00				1.19	37.00		1.19	37.00				
S0128	006	0		29	10	S0128_006_0	4	4	Non-Preferred Brand	1	2	110000		1	110100000010101000000111	30		90							2	30		90							30		31	14	31	14					93.63	27		27																					27		27																	27				27			27			
S0128	006	0		29	10	S0128_006_0	4	3	Preferred Brand	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	1.23	37.00		111.00																					1.23	37.00		111.00																		37.00				1.19	37.00		1.19	37.00				
S0128	006	0		29	10	S0128_006_0	4	1	Preferred Generic	1	2	001010		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.03	1.00		3.00																					0.03	1.00		3.00																		1.00				0.03	1.00		0.03	1.00				
S0128	006	0		29	10	S0128_006_0	4	2	Non-Preferred Generic	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.08	2.50		7.50																					0.08	2.50		7.50																		2.50				0.08	2.50		0.08	2.50				
S0128	007	0		29	10	S0128_007_0	4	3	Preferred Brand	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	1.17	35.00		105.00																					1.17	35.00		105.00																		35.00				1.13	35.00		1.13	35.00				
S0128	007	0		29	10	S0128_007_0	4	1	Preferred Generic	1	2	001010		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.03	1.00		3.00																					0.03	1.00		3.00																		1.00				0.03	1.00		0.03	1.00				
S0128	007	0		29	10	S0128_007_0	4	2	Non-Preferred Generic	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.08	2.50		7.50																					0.08	2.50		7.50																		2.50				0.08	2.50		0.08	2.50				
S0128	007	0		29	10	S0128_007_0	4	4	Non-Preferred Brand	1	2	110000		1	110100000010101000000111	30		90							2	30		90							30		31	14	31	14					88.46	27		27																					27		27																	27				27			27			
S0128	008	0		29	10	S0128_008_0	4	1	Preferred Generic	1	2	001010		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.03	1.00		3.00																					0.03	1.00		3.00																		1.00				0.03	1.00		0.03	1.00				
S0128	008	0		29	10	S0128_008_0	4	2	Non-Preferred Generic	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.08	2.50		7.50																					0.08	2.50		7.50																		2.50				0.08	2.50		0.08	2.50				
S0128	008	0		29	10	S0128_008_0	4	3	Preferred Brand	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	1.17	35.00		105.00																					1.17	35.00		105.00																		35.00				1.13	35.00		1.13	35.00				
S0128	008	0		29	10	S0128_008_0	4	4	Non-Preferred Brand	1	2	110000		1	110100000010101000000111	30		90							2	30		90							30		31	14	31	14					87.46	27		27																					27		27																	27				27			27			
S0128	009	0		29	10	S0128_009_0	4	2	Non-Preferred Generic	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.08	2.50		7.50																					0.08	2.50		7.50																		2.50				0.08	2.50		0.08	2.50				
S0128	009	0		29	10	S0128_009_0	4	3	Preferred Brand	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	1.20	36.00		108.00																					1.20	36.00		108.00																		36.00				1.16	36.00		1.16	36.00				
S0128	009	0		29	10	S0128_009_0	4	1	Preferred Generic	1	2	001010		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.03	1.00		3.00																					0.03	1.00		3.00																		1.00				0.03	1.00		0.03	1.00				
S0128	009	0		29	10	S0128_009_0	4	4	Non-Preferred Brand	1	2	110000		1	110100000010101000000111	30		90							2	30		90							30		31	14	31	14					89.08	27		27																					27		27																	27				27			27			
S0128	010	0		29	10	S0128_010_0	4	3	Preferred Brand	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	1.17	35.00		105.00																					1.17	35.00		105.00																		35.00				1.13	35.00		1.13	35.00				
S0128	010	0		29	10	S0128_010_0	4	2	Non-Preferred Generic	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.08	2.50		7.50																					0.08	2.50		7.50																		2.50				0.08	2.50		0.08	2.50				
S0128	010	0		29	10	S0128_010_0	4	1	Preferred Generic	1	2	001010		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.03	1.00		3.00																					0.03	1.00		3.00																		1.00				0.03	1.00		0.03	1.00				
S0128	010	0		29	10	S0128_010_0	4	4	Non-Preferred Brand	1	2	110000		1	110100000010101000000111	30		90							2	30		90							30		31	14	31	14					89.02	27		27																					27		27																	27				27			27			
S0128	011	0		29	10	S0128_011_0	4	1	Preferred Generic	1	2	001010		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.03	1.00		3.00																					0.03	1.00		3.00																		1.00				0.03	1.00		0.03	1.00				
S0128	011	0		29	10	S0128_011_0	4	2	Non-Preferred Generic	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.08	2.50		7.50																					0.08	2.50		7.50																		2.50				0.08	2.50		0.08	2.50				
S0128	011	0		29	10	S0128_011_0	4	3	Preferred Brand	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	1.13	34.00		102.00																					1.13	34.00		102.00																		34.00				1.10	34.00		1.10	34.00				
S0128	011	0		29	10	S0128_011_0	4	4	Non-Preferred Brand	1	2	110000		1	110100000010101000000111	30		90							2	30		90							30		31	14	31	14					87.66	27		27																					27		27																	27				27			27			
S0128	012	0		29	10	S0128_012_0	4	3	Preferred Brand	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	1.20	36.00		108.00																					1.20	36.00		108.00																		36.00				1.16	36.00		1.16	36.00				
S0128	012	0		29	10	S0128_012_0	4	4	Non-Preferred Brand	1	2	110000		1	110100000010101000000111	30		90							2	30		90							30		31	14	31	14					92.00	27		27																					27		27																	27				27			27			
S0128	012	0		29	10	S0128_012_0	4	1	Preferred Generic	1	2	001010		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.03	1.00		3.00																					0.03	1.00		3.00																		1.00				0.03	1.00		0.03	1.00				
S0128	012	0		29	10	S0128_012_0	4	2	Non-Preferred Generic	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.08	2.50		7.50																					0.08	2.50		7.50																		2.50				0.08	2.50		0.08	2.50				
S0128	013	0		29	10	S0128_013_0	4	1	Preferred Generic	1	2	001010		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.03	1.00		3.00																					0.03	1.00		3.00																		1.00				0.03	1.00		0.03	1.00				
S0128	013	0		29	10	S0128_013_0	4	3	Preferred Brand	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	1.13	34.00		102.00																					1.13	34.00		102.00																		34.00				1.10	34.00		1.10	34.00				
S0128	013	0		29	10	S0128_013_0	4	4	Non-Preferred Brand	1	2	110000		1	110100000010101000000111	30		90							2	30		90							30		31	14	31	14					84.97	27		27																					27		27																	27				27			27			
S0128	013	0		29	10	S0128_013_0	4	2	Non-Preferred Generic	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.08	2.50		7.50																					0.08	2.50		7.50																		2.50				0.08	2.50		0.08	2.50				
S0128	014	0		29	10	S0128_014_0	4	3	Preferred Brand	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	1.20	36.00		108.00																					1.20	36.00		108.00																		36.00				1.16	36.00		1.16	36.00				
S0128	014	0		29	10	S0128_014_0	4	2	Non-Preferred Generic	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.08	2.50		7.50																					0.08	2.50		7.50																		2.50				0.08	2.50		0.08	2.50				
S0128	014	0		29	10	S0128_014_0	4	1	Preferred Generic	1	2	001010		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.03	1.00		3.00																					0.03	1.00		3.00																		1.00				0.03	1.00		0.03	1.00				
S0128	014	0		29	10	S0128_014_0	4	4	Non-Preferred Brand	1	2	110000		1	110100000010101000000111	30		90							2	30		90							30		31	14	31	14					89.81	27		27																					27		27																	27				27			27			
S0128	015	0		29	10	S0128_015_0	4	4	Non-Preferred Brand	1	2	110000		1	110100000010101000000111	30		90							2	30		90							30		31	14	31	14					87.52	27		27																					27		27																	27				27			27			
S0128	015	0		29	10	S0128_015_0	4	1	Preferred Generic	1	2	001010		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.03	1.00		3.00																					0.03	1.00		3.00																		1.00				0.03	1.00		0.03	1.00				
S0128	015	0		29	10	S0128_015_0	4	2	Non-Preferred Generic	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.08	2.50		7.50																					0.08	2.50		7.50																		2.50				0.08	2.50		0.08	2.50				
S0128	015	0		29	10	S0128_015_0	4	3	Preferred Brand	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	1.17	35.00		105.00																					1.17	35.00		105.00																		35.00				1.13	35.00		1.13	35.00				
S0128	016	0		29	10	S0128_016_0	4	1	Preferred Generic	1	2	001010		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.03	1.00		3.00																					0.03	1.00		3.00																		1.00				0.03	1.00		0.03	1.00				
S0128	016	0		29	10	S0128_016_0	4	2	Non-Preferred Generic	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.08	2.50		7.50																					0.08	2.50		7.50																		2.50				0.08	2.50		0.08	2.50				
S0128	016	0		29	10	S0128_016_0	4	3	Preferred Brand	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	1.13	34.00		102.00																					1.13	34.00		102.00																		34.00				1.10	34.00		1.10	34.00				
S0128	016	0		29	10	S0128_016_0	4	4	Non-Preferred Brand	1	2	110000		1	110100000010101000000111	30		90							2	30		90							30		31	14	31	14					85.28	27		27																					27		27																	27				27			27			
S0128	017	0		29	10	S0128_017_0	4	3	Preferred Brand	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	1.20	36.00		108.00																					1.20	36.00		108.00																		36.00				1.16	36.00		1.16	36.00				
S0128	017	0		29	10	S0128_017_0	4	4	Non-Preferred Brand	1	2	110000		1	110100000010101000000111	30		90							2	30		90							30		31	14	31	14					89.42	27		27																					27		27																	27				27			27			
S0128	017	0		29	10	S0128_017_0	4	2	Non-Preferred Generic	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.08	2.50		7.50																					0.08	2.50		7.50																		2.50				0.08	2.50		0.08	2.50				
S0128	017	0		29	10	S0128_017_0	4	1	Preferred Generic	1	2	001010		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.03	1.00		3.00																					0.03	1.00		3.00																		1.00				0.03	1.00		0.03	1.00				
S0128	018	0		29	10	S0128_018_0	4	3	Preferred Brand	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	1.17	35.00		105.00																					1.17	35.00		105.00																		35.00				1.13	35.00		1.13	35.00				
S0128	018	0		29	10	S0128_018_0	4	4	Non-Preferred Brand	1	2	110000		1	110100000010101000000111	30		90							2	30		90							30		31	14	31	14					88.57	27		27																					27		27																	27				27			27			
S0128	018	0		29	10	S0128_018_0	4	1	Preferred Generic	1	2	001010		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.03	1.00		3.00																					0.03	1.00		3.00																		1.00				0.03	1.00		0.03	1.00				
S0128	018	0		29	10	S0128_018_0	4	2	Non-Preferred Generic	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.08	2.50		7.50																					0.08	2.50		7.50																		2.50				0.08	2.50		0.08	2.50				
S0128	019	0		29	10	S0128_019_0	4	3	Preferred Brand	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	1.17	35.00		105.00																					1.17	35.00		105.00																		35.00				1.13	35.00		1.13	35.00				
S0128	019	0		29	10	S0128_019_0	4	2	Non-Preferred Generic	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.08	2.50		7.50																					0.08	2.50		7.50																		2.50				0.08	2.50		0.08	2.50				
S0128	019	0		29	10	S0128_019_0	4	1	Preferred Generic	1	2	001010		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.03	1.00		3.00																					0.03	1.00		3.00																		1.00				0.03	1.00		0.03	1.00				
S0128	019	0		29	10	S0128_019_0	4	4	Non-Preferred Brand	1	2	110000		1	110100000010101000000111	30		90							2	30		90							30		31	14	31	14					86.73	27		27																					27		27																	27				27			27			
S0128	020	0		29	10	S0128_020_0	4	1	Preferred Generic	1	2	001010		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.03	1.00		3.00																					0.03	1.00		3.00																		1.00				0.03	1.00		0.03	1.00				
S0128	020	0		29	10	S0128_020_0	4	2	Non-Preferred Generic	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.08	2.50		7.50																					0.08	2.50		7.50																		2.50				0.08	2.50		0.08	2.50				
S0128	020	0		29	10	S0128_020_0	4	4	Non-Preferred Brand	1	2	110000		1	110100000010101000000111	30		90							2	30		90							30		31	14	31	14					86.96	27		27																					27		27																	27				27			27			
S0128	020	0		29	10	S0128_020_0	4	3	Preferred Brand	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	1.13	34.00		102.00																					1.13	34.00		102.00																		34.00				1.10	34.00		1.10	34.00				
S0128	021	0		29	10	S0128_021_0	4	1	Preferred Generic	1	2	001010		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.03	1.00		3.00																					0.03	1.00		3.00																		1.00				0.03	1.00		0.03	1.00				
S0128	021	0		29	10	S0128_021_0	4	3	Preferred Brand	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	1.10	33.00		99.00																					1.10	33.00		99.00																		33.00				1.06	33.00		1.06	33.00				
S0128	021	0		29	10	S0128_021_0	4	2	Non-Preferred Generic	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.08	2.50		7.50																					0.08	2.50		7.50																		2.50				0.08	2.50		0.08	2.50				
S0128	021	0		29	10	S0128_021_0	4	4	Non-Preferred Brand	1	2	110000		1	110100000010101000000111	30		90							2	30		90							30		31	14	31	14					85.33	27		27																					27		27																	27				27			27			
S0128	022	0		29	10	S0128_022_0	4	3	Preferred Brand	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	1.13	34.00		102.00																					1.13	34.00		102.00																		34.00				1.10	34.00		1.10	34.00				
S0128	022	0		29	10	S0128_022_0	4	2	Non-Preferred Generic	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.08	2.50		7.50																					0.08	2.50		7.50																		2.50				0.08	2.50		0.08	2.50				
S0128	022	0		29	10	S0128_022_0	4	1	Preferred Generic	1	2	001010		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.03	1.00		3.00																					0.03	1.00		3.00																		1.00				0.03	1.00		0.03	1.00				
S0128	022	0		29	10	S0128_022_0	4	4	Non-Preferred Brand	1	2	110000		1	110100000010101000000111	30		90							2	30		90							30		31	14	31	14					86.07	27		27																					27		27																	27				27			27			
S0128	023	0		29	10	S0128_023_0	4	1	Preferred Generic	1	2	001010		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.03	1.00		3.00																					0.03	1.00		3.00																		1.00				0.03	1.00		0.03	1.00				
S0128	023	0		29	10	S0128_023_0	4	2	Non-Preferred Generic	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.08	2.50		7.50																					0.08	2.50		7.50																		2.50				0.08	2.50		0.08	2.50				
S0128	023	0		29	10	S0128_023_0	4	3	Preferred Brand	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	1.17	35.00		105.00																					1.17	35.00		105.00																		35.00				1.13	35.00		1.13	35.00				
S0128	023	0		29	10	S0128_023_0	4	4	Non-Preferred Brand	1	2	110000		1	110100000010101000000111	30		90							2	30		90							30		31	14	31	14					90.81	27		27																					27		27																	27				27			27			
S0128	024	0		29	10	S0128_024_0	4	1	Preferred Generic	1	2	001010		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.03	1.00		3.00																					0.03	1.00		3.00																		1.00				0.03	1.00		0.03	1.00				
S0128	024	0		29	10	S0128_024_0	4	2	Non-Preferred Generic	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.08	2.50		7.50																					0.08	2.50		7.50																		2.50				0.08	2.50		0.08	2.50				
S0128	024	0		29	10	S0128_024_0	4	3	Preferred Brand	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	1.17	35.00		105.00																					1.17	35.00		105.00																		35.00				1.13	35.00		1.13	35.00				
S0128	024	0		29	10	S0128_024_0	4	4	Non-Preferred Brand	1	2	110000		1	110100000010101000000111	30		90							2	30		90							30		31	14	31	14					87.97	27		27																					27		27																	27				27			27			
S0128	025	0		29	10	S0128_025_0	4	4	Non-Preferred Brand	1	2	110000		1	110100000010101000000111	30		90							2	30		90							30		31	14	31	14					88.62	27		27																					27		27																	27				27			27			
S0128	025	0		29	10	S0128_025_0	4	1	Preferred Generic	1	2	001010		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.03	1.00		3.00																					0.03	1.00		3.00																		1.00				0.03	1.00		0.03	1.00				
S0128	025	0		29	10	S0128_025_0	4	2	Non-Preferred Generic	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.08	2.50		7.50																					0.08	2.50		7.50																		2.50				0.08	2.50		0.08	2.50				
S0128	025	0		29	10	S0128_025_0	4	3	Preferred Brand	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	1.20	36.00		108.00																					1.20	36.00		108.00																		36.00				1.16	36.00		1.16	36.00				
S0128	026	0		29	10	S0128_026_0	4	1	Preferred Generic	1	2	001010		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.03	1.00		3.00																					0.03	1.00		3.00																		1.00				0.03	1.00		0.03	1.00				
S0128	026	0		29	10	S0128_026_0	4	2	Non-Preferred Generic	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.08	2.50		7.50																					0.08	2.50		7.50																		2.50				0.08	2.50		0.08	2.50				
S0128	026	0		29	10	S0128_026_0	4	3	Preferred Brand	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	1.23	37.00		111.00																					1.23	37.00		111.00																		37.00				1.19	37.00		1.19	37.00				
S0128	026	0		29	10	S0128_026_0	4	4	Non-Preferred Brand	1	2	110000		1	110100000010101000000111	30		90							2	30		90							30		31	14	31	14					91.23	27		27																					27		27																	27				27			27			
S0128	027	0		29	10	S0128_027_0	5	4	Non-Preferred Brand	1	2	110000		1	110100000010101000000111	30		90							2	30		90							30		31	14	31	14					90.80	27		27																					27		27																	27				27			27			
S0128	027	0		29	10	S0128_027_0	5	3	Preferred Brand	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	1.17	35.00		105.00																					1.17	35.00		105.00																		35.00				1.13	35.00		1.13	35.00				
S0128	027	0		29	10	S0128_027_0	5	2	Non-Preferred Generic	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.08	2.50		7.50																					0.08	2.50		7.50																		2.50				0.08	2.50		0.08	2.50				
S0128	027	0		29	10	S0128_027_0	5	1	Preferred Generic	1	2	001010		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.03	1.00		3.00																					0.03	1.00		3.00																		1.00				0.03	1.00		0.03	1.00				
S0128	028	0		29	10	S0128_028_0	4	4	Non-Preferred Brand	1	2	110000		1	110100000010101000000111	30		90							2	30		90							30		31	14	31	14					91.43	27		27																					27		27																	27				27			27			
S0128	028	0		29	10	S0128_028_0	4	3	Preferred Brand	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	1.23	37.00		111.00																					1.23	37.00		111.00																		37.00				1.19	37.00		1.19	37.00				
S0128	028	0		29	10	S0128_028_0	4	2	Non-Preferred Generic	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.08	2.50		7.50																					0.08	2.50		7.50																		2.50				0.08	2.50		0.08	2.50				
S0128	028	0		29	10	S0128_028_0	4	1	Preferred Generic	1	2	001010		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.03	1.00		3.00																					0.03	1.00		3.00																		1.00				0.03	1.00		0.03	1.00				
S0128	029	0		29	10	S0128_029_0	4	2	Non-Preferred Generic	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.08	2.50		7.50																					0.08	2.50		7.50																		2.50				0.08	2.50		0.08	2.50				
S0128	029	0		29	10	S0128_029_0	4	4	Non-Preferred Brand	1	2	110000		1	110100000010101000000111	30		90							2	30		90							30		31	14	31	14					87.06	27		27																					27		27																	27				27			27			
S0128	029	0		29	10	S0128_029_0	4	3	Preferred Brand	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	1.10	33.00		99.00																					1.10	33.00		99.00																		33.00				1.06	33.00		1.06	33.00				
S0128	029	0		29	10	S0128_029_0	4	1	Preferred Generic	1	2	001010		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.03	1.00		3.00																					0.03	1.00		3.00																		1.00				0.03	1.00		0.03	1.00				
S0128	030	0		29	10	S0128_030_0	4	2	Non-Preferred Generic	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.08	2.50		7.50																					0.08	2.50		7.50																		2.50				0.08	2.50		0.08	2.50				
S0128	030	0		29	10	S0128_030_0	4	4	Non-Preferred Brand	1	2	110000		1	110100000010101000000111	30		90							2	30		90							30		31	14	31	14					92.27	27		27																					27		27																	27				27			27			
S0128	030	0		29	10	S0128_030_0	4	3	Preferred Brand	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	1.23	37.00		111.00																					1.23	37.00		111.00																		37.00				1.19	37.00		1.19	37.00				
S0128	030	0		29	10	S0128_030_0	4	1	Preferred Generic	1	2	001010		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.03	1.00		3.00																					0.03	1.00		3.00																		1.00				0.03	1.00		0.03	1.00				
S0128	031	0		29	10	S0128_031_0	4	3	Preferred Brand	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	1.17	35.00		105.00																					1.17	35.00		105.00																		35.00				1.13	35.00		1.13	35.00				
S0128	031	0		29	10	S0128_031_0	4	2	Non-Preferred Generic	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.08	2.50		7.50																					0.08	2.50		7.50																		2.50				0.08	2.50		0.08	2.50				
S0128	031	0		29	10	S0128_031_0	4	4	Non-Preferred Brand	1	2	110000		1	110100000010101000000111	30		90							2	30		90							30		31	14	31	14					87.45	27		27																					27		27																	27				27			27			
S0128	031	0		29	10	S0128_031_0	4	1	Preferred Generic	1	2	001010		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.03	1.00		3.00																					0.03	1.00		3.00																		1.00				0.03	1.00		0.03	1.00				
S0128	032	0		29	10	S0128_032_0	4	1	Preferred Generic	1	2	001010		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.03	1.00		3.00																					0.03	1.00		3.00																		1.00				0.03	1.00		0.03	1.00				
S0128	032	0		29	10	S0128_032_0	4	4	Non-Preferred Brand	1	2	110000		1	110100000010101000000111	30		90							2	30		90							30		31	14	31	14					89.35	27		27																					27		27																	27				27			27			
S0128	032	0		29	10	S0128_032_0	4	2	Non-Preferred Generic	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.08	2.50		7.50																					0.08	2.50		7.50																		2.50				0.08	2.50		0.08	2.50				
S0128	032	0		29	10	S0128_032_0	4	3	Preferred Brand	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	1.20	36.00		108.00																					1.20	36.00		108.00																		36.00				1.16	36.00		1.16	36.00				
S0128	033	0		29	10	S0128_033_0	4	1	Preferred Generic	1	2	001010		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.03	1.00		3.00																					0.03	1.00		3.00																		1.00				0.03	1.00		0.03	1.00				
S0128	033	0		29	10	S0128_033_0	4	3	Preferred Brand	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	1.23	37.00		111.00																					1.23	37.00		111.00																		37.00				1.19	37.00		1.19	37.00				
S0128	033	0		29	10	S0128_033_0	4	2	Non-Preferred Generic	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.08	2.50		7.50																					0.08	2.50		7.50																		2.50				0.08	2.50		0.08	2.50				
S0128	033	0		29	10	S0128_033_0	4	4	Non-Preferred Brand	1	2	110000		1	110100000010101000000111	30		90							2	30		90							30		31	14	31	14					92.60	27		27																					27		27																	27				27			27			
S0128	034	0		29	10	S0128_034_0	4	4	Non-Preferred Brand	1	2	110000		1	110100000010101000000111	30		90							2	30		90							30		31	14	31	14					93.93	27		27																					27		27																	27				27			27			
S0128	034	0		29	10	S0128_034_0	4	3	Preferred Brand	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	1.20	36.00		108.00																					1.20	36.00		108.00																		36.00				1.16	36.00		1.16	36.00				
S0128	034	0		29	10	S0128_034_0	4	2	Non-Preferred Generic	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.08	2.50		7.50																					0.08	2.50		7.50																		2.50				0.08	2.50		0.08	2.50				
S0128	034	0		29	10	S0128_034_0	4	1	Preferred Generic	1	2	001010		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.03	1.00		3.00																					0.03	1.00		3.00																		1.00				0.03	1.00		0.03	1.00				
S0128	035	0		29	10	S0128_035_0	4	1	Preferred Generic	1	2	001010		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.03	1.00		3.00																					0.03	1.00		3.00																		1.00				0.03	1.00		0.03	1.00				
S0128	035	0		29	10	S0128_035_0	4	2	Non-Preferred Generic	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.08	2.50		7.50																					0.08	2.50		7.50																		2.50				0.08	2.50		0.08	2.50				
S0128	035	0		29	10	S0128_035_0	4	3	Preferred Brand	1	2	000101		2	110100000010101000000111	30		90							2	30		90							30		31	14	31	14	0.97	29.00		87.00																					0.97	29.00		87.00																		29.00				0.94	29.00		0.94	29.00				
S0128	035	0		29	10	S0128_035_0	4	4	Non-Preferred Brand	1	2	110000		1	110100000010101000000111	30		90							2	30		90							30		31	14	31	14					77.01	27		27																					27		27																	27				27			27			
S0197	005	0		29	10	S0197_005_0	2	1	Preferred Generic	1	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00							
S0197	005	0		29	10	S0197_005_0	2	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					20.00		60.00																						20.00		50.00																		20.00					20.00							
S0197	005	0		29	10	S0197_005_0	2	3	Preferred Brand	1	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					44.34	25		25																					25		25																	25							25			
S0197	005	0		29	10	S0197_005_0	2	4	Non-Preferred Brand	3	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					222.33	43		43																					43		43																	43				43			43	2	1	
S0197	005	0		29	10	S0197_005_0	2	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					279.65	33																																										33				33			33			
S0197	005	0		29	10	S0197_005_0	2	1	Preferred Generic	3	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					3.00		9.00																						3.00		7.50																		3.00					3.00					1		
S0197	005	0		29	10	S0197_005_0	2	3	Preferred Brand	3	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					216.79	25		25																					25		25																	25							25	2		1
S0197	005	0		29	10	S0197_005_0	2	4	Non-Preferred Brand	1	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					66.69	43		43																					43		43																	43				43			43			
S0223	001	0		29	10	S0223_001_0	4	4	Non-Preferred Brand	1	2	100000		2	110100000010001000000001	30		90							2			90							30				31	14		90.00		270.00																								270.00																		90.00								90.00				
S0223	001	0		29	10	S0223_001_0	4	3	Preferred Brand	1	2	000001		2	110100000010001000000001	30		90							2			90							30				31	14		45.00		135.00																								135.00																		45.00								45.00				
S0223	001	0		29	10	S0223_001_0	4	2	Non-Preferred Generic	1	2	000100		2	010100000010001000000100	30		90							2			90							30		31					8.00		24.00																								24.00																		8.00					8.00							
S0223	001	0		29	10	S0223_001_0	4	1	Preferred Generic	1	2	001000		2	010100000010001000000100	30		90							1			90							30		31					2.00		6.00																								6.00																		2.00					2.00							
S0223	001	0		29	10	S0223_001_0	4	5	Specialty Tier	1	2	000001		1	110000000010000000000001	30																			30				31	14					3.81	25																																										25							25			
S0223	002	0		29	10	S0223_002_0	5	5	Specialty Tier	1	4	000010	1	1	110000000010000000000001	30																			30				31	14					1376.00	25																																										25							25			
S0223	002	0		29	10	S0223_002_0	5	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							2			90							30				31	14		95.00		285.00																								285.00																		95.00								95.00				
S0223	002	0		29	10	S0223_002_0	5	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		45.00		135.00																								135.00																		45.00								45.00				
S0223	002	0		29	10	S0223_002_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							2			90							30		31					10.00		30.00																								30.00																		10.00					10.00							
S0223	002	0		29	10	S0223_002_0	5	1	Preferred Generic	1	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					2.00		6.00																								6.00																		2.00					2.00							
S0223	002	0		29	10	S0223_002_0	5	1	Preferred Generic	3	4	001000	1	2	010100000010001000000100	30		90							1			90							30		31					2.00		6.00																								6.00																		2.00					2.00					1		
S1030	001	0		29	10	S1030_001_0	1	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				30		90	30		90	1	30		90							30		31													4.00		8.00						4.00		12.00						4.00		8.00																		4.00					4.00							
S1030	001	0		29	10	S1030_001_0	1	2	Non-Preferred Generic	1	4	000100	1	2	000010110110101000000100				30		90	30		90	1	30		90							30		31													8.00		16.00						8.00		24.00						8.00		16.00																		8.00					8.00							
S1030	001	0		29	10	S1030_001_0	1	3	Preferred Brand	1	4	000001	1	2	100010110110101000000001				30		90	30		90	1	30		90							30				31	14										40.00		80.00						40.00		120.00						40.00		80.00																		40.00								40.00				
S1030	001	0		29	10	S1030_001_0	1	4	Non-Preferred Brand	1	4	100000	1	2	100010110110101000000001				30		90	30		90	1	30		90							30				31	14										65.00		130.00						65.00		195.00						65.00		130.00																		65.00								65.00				
S1030	001	0		29	10	S1030_001_0	1	5	Specialty Tier	1	4	010010	1	1	100010110110101000000101				30		90	30		90	1	30		90							30		31		31	14													771.25	33		33					771.25	33		33					33		33																	33				33			33			
S1030	006	0		29	10	S1030_006_0	1	4	Non-Preferred Brand	1	2	100000		2	100010110110101000000001				30		90	30		90	1	30		90							30				31	14										85.00		170.00						85.00		255.00						85.00		170.00																		85.00								85.00				
S1030	006	0		29	10	S1030_006_0	1	5	Specialty Tier	1	2	010010		1	100010110110101000000101				30		90	30		90	1	30		90							30		31		31	14													556.07	25		25					556.07	25		25					25		25																	25				25			25			
S1030	006	0		29	10	S1030_006_0	1	3	Preferred Brand	1	2	000001		2	100010110110101000000001				30		90	30		90	1	30		90							30				31	14										35.00		70.00						35.00		105.00						35.00		70.00																		35.00								35.00				
S1030	006	0		29	10	S1030_006_0	1	2	Non-Preferred Generic	1	2	000100		2	000010110110101000000100				30		90	30		90	1	30		90							30		31													8.00		16.00						8.00		24.00						8.00		16.00																		8.00					8.00							
S1030	006	0		29	10	S1030_006_0	1	1	Preferred Generic	1	2	001000		2	000010110110101000000100				30		90	30		90	1	30		90							30		31													4.00		8.00						4.00		12.00						4.00		8.00																		4.00					4.00							
S1140	001	0		29	10	S1140_001_0	4	5	Specialty Tier	1	3	010010		1	110100000001101000000111	30		90							2	30		90								14	31	14	31	14					428.34	25		25																					25		25																		25			25			25			
S1140	001	0		29	10	S1140_001_0	4	4	Non-Preferred Brand	1	3	100000		2	110100000001101000000001	30		90							2	30		90								14			31	14		75.00		225.00																						75.00		187.50																			75.00							75.00				
S1140	001	0		29	10	S1140_001_0	4	3	Preferred Brand	1	3	000001		2	110100000001101000000001	30		90							2	30		90								14			31	14		45.00		135.00																						45.00		112.50																			45.00							45.00				
S1140	001	0		29	10	S1140_001_0	4	2	Non-Preferred Generic	1	3	000100		2	010100000001101000000110	30		90							2	30		90								14	31	14				10.00		30.00																						10.00		25.00																			10.00				10.00							
S1140	001	0		29	10	S1140_001_0	4	1	Preferred Generic	1	3	001000		2	010100000001101000000110	30		90							2	30		90								14	31	14				0.00		0.00																						0.00		0.00																			0.00				0.00							
S2321	002	0		29	10	S2321_002_0	2	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				5.00		15.00																								10.00																		5.00					5.00							
S2321	002	0		29	10	S2321_002_0	2	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				10.00		30.00																								20.00																		10.00					10.00							
S2321	002	0		29	10	S2321_002_0	2	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		30.00		90.00																								60.00																		30.00								30.00				
S2321	002	0		29	10	S2321_002_0	2	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				10.00		30.00																								20.00																		10.00					10.00					1		
S2321	002	0		29	10	S2321_002_0	2	5	Specialty Tier	1	4	100000	1	1	110100000010001000000001	30		90							1			90							30				31	14					169.09	25		25																							25																	25							25			
S2321	002	0		29	10	S2321_002_0	2	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				5.00		15.00																								10.00																		5.00					5.00					1		
S2321	002	0		29	10	S2321_002_0	2	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		65.00		195.00																								130.00																		65.00								65.00				
S2321	005	0		29	10	S2321_005_0	2	2	Preferred Brand	1	3	000001		2	110100000010001000000001	30		90							1			90							30				31	14		45.00		135.00																								90.00																		45.00								45.00				
S2321	005	0		29	10	S2321_005_0	2	3	Non-Preferred Brand	1	3	100000		2	110100000010001000000001	30		90							1			90							30				31	14		85.00		255.00																								170.00																		85.00								85.00				
S2321	005	0		29	10	S2321_005_0	2	4	Specialty Tier	1	3	100000		1	110100000010001000000001	30		90							1			90							30				31	14					39.88	25		25																							25																	25							25			
S2321	005	0		29	10	S2321_005_0	2	1	Generic	1	3	010000		2	010100000010001000000110	30		90							1			90							30		31	14				5.00		15.00																								10.00																		5.00					5.00							
S2468	003	0		29	10	S2468_003_0	5	3	Non-Preferred Brand	1	2	100000		2	100010110110001000000001				30		90	30		90	1			90							30				31	14										76.00		152.00						76.00		228.00								152.00																		76.00								76.00				
S2468	003	0		29	10	S2468_003_0	5	5	Specialty Tier	1	2	010010		1	100010110110001000000101				30		90	30		90	1			90							30		31		31	14													884.00	25		25					884.00	25		25							25																	25				25			25			
S2468	003	0		29	10	S2468_003_0	5	4	Injectable Drugs	1	2	010010		1	100010110110001000000101				30		90	30		90	1			90							30		31		31	14													196.00	25		25					196.00	25		25							25																	25				25			25			
S2468	003	0		29	10	S2468_003_0	5	2	Preferred Brand	1	2	000101		2	100010110110001000000101				30		90	30		90	1			90							30		31		31	14										37.00		74.00						37.00		111.00								74.00																		37.00					37.00			37.00				
S2468	003	0		29	10	S2468_003_0	5	1	Preferred Generic	1	2	001000		2	000010110110001000000100				30		90	30		90	1			90							30		31													4.00		8.00						4.00		12.00								8.00																		4.00					4.00							
S2468	004	0		29	10	S2468_004_0	7	1	Preferred Generic	1	4	001000	3	2	000010110110001000000100				30		90	30		90	1			90							30		31													5.00		10.00						5.00		15.00								10.00																		5.00					5.00							
S2468	004	0		29	10	S2468_004_0	7	2	Preferred Brand	1	4	000101	1	2	100010110110001000000101				30		90	30		90	1			90							30		31		31	14										45.00		90.00						45.00		135.00								90.00																		45.00					45.00			45.00				
S2468	004	0		29	10	S2468_004_0	7	5	Specialty Tier	1	4	010010	1	1	100010110110001000000101				30		90	30		90	1			90							30		31		31	14													1167.00	33		33					1167.00	33		33							33																	33				33			33			
S2468	004	0		29	10	S2468_004_0	7	3	Non-Preferred Brand	1	4	100000	1	2	100010110110001000000001				30		90	30		90	1			90							30				31	14										90.00		180.00						90.00		270.00								180.00																		90.00								90.00				
S2468	004	0		29	10	S2468_004_0	7	4	Injectable Drugs	1	4	010010	1	1	100010110110001000000101				30		90	30		90	1			90							30		31		31	14													196.00	25		25					196.00	25		25							25																	25				25			25			
S2505	001	0		29	10	S2505_001_0	2	4	Specialty Tier	1	2	010010		1	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14					146.86	25	25	25																												25	25	25					25	25	25			25				25			25			
S2505	001	0		29	10	S2505_001_0	2	3	Non-Preferred Brand	1	2	100100		2	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14		80.00	160.00	240.00																													80.00	160.00	240.00					160.00	320.00	480.00				80.00					80.00			80.00				
S2505	001	0		29	10	S2505_001_0	2	2	Preferred Brand	1	2	000001		2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		38.00	76.00	114.00																													38.00	76.00	114.00					76.00	152.00	228.00				38.00								38.00				
S2505	001	0		29	10	S2505_001_0	2	1	Generic	1	2	010000		2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					6.00	12.00	18.00																													6.00	12.00	18.00					12.00	24.00	36.00				6.00					6.00							
S2505	003	0		29	10	S2505_003_0	2	2	Preferred Brand	1	2	000001		2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		40.00	80.00	120.00																													40.00	80.00	120.00					80.00	160.00	240.00				40.00								40.00				
S2505	003	0		29	10	S2505_003_0	2	3	Non-Preferred Brand	1	2	100100		2	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14		80.00	160.00	240.00																													80.00	160.00	240.00					160.00	320.00	480.00				80.00					80.00			80.00				
S2505	003	0		29	10	S2505_003_0	2	4	Specialty Tier	1	2	010010		1	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14					163.83	25	25	25																												25	25	25					25	25	25			25				25			25			
S2505	003	0		29	10	S2505_003_0	2	1	Generic	1	2	010000		2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					6.00	12.00	18.00																													6.00	12.00	18.00					12.00	24.00	36.00				6.00					6.00							
S2505	005	0		29	10	S2505_005_0	2	2	Preferred Brand	1	2	000001		2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		44.00	88.00	132.00																													44.00	88.00	132.00					88.00	176.00	264.00				44.00								44.00				
S2505	005	0		29	10	S2505_005_0	2	3	Non-Preferred Brand	1	2	100100		2	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14		80.00	160.00	240.00																													80.00	160.00	240.00					160.00	320.00	480.00				80.00					80.00			80.00				
S2505	005	0		29	10	S2505_005_0	2	4	Specialty Tier	1	2	010010		1	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14					201.82	25	25	25																												25	25	25					25	25	25			25				25			25			
S2505	005	0		29	10	S2505_005_0	2	1	Generic	1	2	010000		2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					6.00	12.00	18.00																													6.00	12.00	18.00					12.00	24.00	36.00				6.00					6.00							
S2505	007	0		29	10	S2505_007_0	2	1	Generic	1	2	010000		2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					6.00	12.00	18.00																													6.00	12.00	18.00					12.00	24.00	36.00				6.00					6.00							
S2505	007	0		29	10	S2505_007_0	2	2	Preferred Brand	1	2	000001		2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		44.00	88.00	132.00																													44.00	88.00	132.00					88.00	176.00	264.00				44.00								44.00				
S2505	007	0		29	10	S2505_007_0	2	3	Non-Preferred Brand	1	2	100100		2	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14		85.00	170.00	255.00																													85.00	170.00	255.00					170.00	340.00	510.00				85.00					85.00			85.00				
S2505	007	0		29	10	S2505_007_0	2	4	Specialty Tier	1	2	010010		1	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14					190.39	25	25	25																												25	25	25					25	25	25			25				25			25			
S2505	009	0		29	10	S2505_009_0	2	3	Non-Preferred Brand	1	2	100100		2	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14		80.00	160.00	240.00																													80.00	160.00	240.00					160.00	320.00	480.00				80.00					80.00			80.00				
S2505	009	0		29	10	S2505_009_0	2	2	Preferred Brand	1	2	000001		2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		38.00	76.00	114.00																													38.00	76.00	114.00					76.00	152.00	228.00				38.00								38.00				
S2505	009	0		29	10	S2505_009_0	2	1	Generic	1	2	010000		2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					6.00	12.00	18.00																													6.00	12.00	18.00					12.00	24.00	36.00				6.00					6.00							
S2505	009	0		29	10	S2505_009_0	2	4	Specialty Tier	1	2	010010		1	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14					156.44	25	25	25																												25	25	25					25	25	25			25				25			25			
S2505	010	0		29	10	S2505_010_0	2	4	Specialty Tier	1	2	010010		1	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14					149.68	25	25	25																												25	25	25					25	25	25			25				25			25			
S2505	010	0		29	10	S2505_010_0	2	3	Non-Preferred Brand	1	2	100100		2	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14		80.00	160.00	240.00																													80.00	160.00	240.00					160.00	320.00	480.00				80.00					80.00			80.00				
S2505	010	0		29	10	S2505_010_0	2	1	Generic	1	2	010000		2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					6.00	12.00	18.00																													6.00	12.00	18.00					12.00	24.00	36.00				6.00					6.00							
S2505	010	0		29	10	S2505_010_0	2	2	Preferred Brand	1	2	000001		2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		35.00	70.00	105.00																													35.00	70.00	105.00					70.00	140.00	210.00				35.00								35.00				
S2874	001	0		29	10	S2874_001_0	2	5	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													779.00	33							765.00	33														33							33					33				33			33			
S2874	001	0		29	10	S2874_001_0	2	4	Non-Preferred Brand	1	4	110000	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										90.00		270.00						90.00		270.00													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
S2874	001	0		29	10	S2874_001_0	2	2	Non-Preferred Generic	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						7.00		21.00													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
S2874	001	0		29	10	S2874_001_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										2.00		6.00						5.00		15.00													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
S2874	001	0		29	10	S2874_001_0	2	3	Preferred Brand	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										43.00		129.00						43.00		129.00													43.00		119.00					43.00		129.00				43.00					43.00			43.00				
S2874	004	0		29	10	S2874_004_0	3	1	Preferred Generic	1	2	001010		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										1.00		3.00						10.00		30.00													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
S2874	004	0		29	10	S2874_004_0	3	5	Specialty Tier	1	2	010010		1	100010010010000100100101				30			30							30			30			30		31		31	14													539.00	25							529.00	25														25							25					25				25			25			
S2874	004	0		29	10	S2874_004_0	3	4	Non-Preferred Brand	1	2	110000		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													86.00	35		35					104.00	43		43												35		35					43		43			43				43			43			
S2874	004	0		29	10	S2874_004_0	3	3	Preferred Brand	1	2	000101		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													18.00	20		20					23.00	25		25												20		20					25		25			25				25			25			
S2874	004	0		29	10	S2874_004_0	3	2	Non-Preferred Generic	1	2	000101		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						19.00		57.00													0.00		0.00					19.00		57.00				19.00					19.00			19.00				
S2893	001	0		29	10	S2893_001_0	3	4	Non-Preferred Brand	1	3	100000		2	110100000010001000000001	30		90							1			90							30				31	14		95.00		285.00																								190.00																		95.00								95.00				
S2893	001	0		29	10	S2893_001_0	3	1	Preferred Generic	1	3	001000		2	010100000010001000000110	30		90							1			90							30		31	14				6.00		18.00																								6.00																		6.00					6.00							
S2893	001	0		29	10	S2893_001_0	3	2	Non-Preferred Generic	1	3	000100		2	010100000010001000000110	30		90							1			90							30		31	14				12.00		36.00																								24.00																		12.00					12.00							
S2893	001	0		29	10	S2893_001_0	3	3	Preferred Brand	1	3	000001		2	110100000010001000000001	30		90							1			90							30				31	14		45.00		135.00																								90.00																		45.00								45.00				
S2893	001	0		29	10	S2893_001_0	3	5	Specialty Tier	1	3	010010		1	110000000010100000000111	30										30									30		31	14	31	14					507.00	26																							26																			26				26			26			
S2893	003	0		29	10	S2893_003_0	3	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				4.00		12.00																								4.00																		4.00					4.00					1		
S2893	003	0		29	10	S2893_003_0	3	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				9.00		27.00																								18.00																		9.00					9.00					1		
S2893	003	0		29	10	S2893_003_0	3	5	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		31	14	31	14					623.00	33																							33																			33				33			33			
S2893	003	0		29	10	S2893_003_0	3	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		30.00		90.00																								60.00																		30.00								30.00				
S2893	003	0		29	10	S2893_003_0	3	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							1			90							30				31	14		70.00		210.00																								140.00																		70.00								70.00				
S2893	003	0		29	10	S2893_003_0	3	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				4.00		12.00																								4.00																		4.00					4.00							
S2893	003	0		29	10	S2893_003_0	3	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				9.00		27.00																								18.00																		9.00					9.00							
S3440	001	0		29	10	S3440_001_0	5	4	Non-Preferred Brand	1	3	100000		1	110100000010001000000001	30		90							1			90							30				31	14					60.14	28		28																							28																	28							28			
S3440	001	0		29	10	S3440_001_0	5	2	Non-Preferred Generic	1	3	000100		2	010100000010001000000100	30		90							1			90							30		31					15.00		37.50																								37.50																		15.00					15.00							
S3440	001	0		29	10	S3440_001_0	5	5	Specialty Tier	1	3	000010		1	110100000010001000000001	30		90							1			90							30				31	14					781.53	28		28																							28																	28							28			
S3440	001	0		29	10	S3440_001_0	5	3	Preferred Brand	1	3	000001		2	110100000010001000000001	30		90							1			90							30				31	14		45.00		112.50																								112.50																		45.00								45.00				
S3440	001	0		29	10	S3440_001_0	5	1	Preferred Generic	1	3	001000		2	010100000010001000000100	30		90							1			90							30		31					5.00		12.50																								12.50																		5.00					5.00							
S3440	004	0		29	10	S3440_004_0	4	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							1			90							30				31	14		40.00		100.00																								100.00																		40.00								40.00				
S3440	004	0		29	10	S3440_004_0	4	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000100	30		90							1			90							30		31					5.00		12.50																								12.50																		5.00					5.00							
S3440	004	0		29	10	S3440_004_0	4	1	Preferred Generic	1	4	001000	3	2	010100000010001000000100	30		90							1			90							30		31					2.00		5.00																								5.00																		2.00					2.00							
S3440	004	0		29	10	S3440_004_0	4	4	Non-Preferred Brand	1	4	100000	1	1	110100000010001000000001	30		90							1			90							30				31	14					60.14	33		33																							33																	33							33			
S3440	004	0		29	10	S3440_004_0	4	5	Specialty Tier	1	4	000010	1	1	110100000010001000000001	30		90							1			90							30				31	14					781.53	33		33																							33																	33							33			
S3521	001	0		29	10	S3521_001_0	2	4	Non-Preferred Brand	1	2	100000		1	100010110110000101101001				30		90	30		90	1				30		90	30		90	30				31	14													88.00	30		30					88.00	35		35												30		30					35		35			35							35			
S3521	001	0		29	10	S3521_001_0	2	3	Preferred Brand	1	2	000001		1	100010110110000101101001				30		90	30		90	1				30		90	30		90	30				31	14													43.00	20		20					43.00	25		25												20		20					25		25			25							25			
S3521	001	0		29	10	S3521_001_0	2	1	Preferred Generic	1	2	001000		2	000010110110000101101110				30		90	30		90	1				30		90	30		90	30		31	14												0.00		0.00						8.00		20.00													0.00		0.00					8.00		20.00				8.00					8.00							
S3521	001	0		29	10	S3521_001_0	2	2	Non-Preferred Generic	1	2	000100		2	000010110110000101101110				30		90	30		90	1				30		90	30		90	30		31	14												5.00		12.50						12.00		30.00													5.00		12.50					12.00		30.00				12.00					12.00							
S4219	001	0		29	10	S4219_001_0	2	3	Preferred Brand	1	3	000001		2	100010110110101000000001				30		90	30		90	1	30		90							30				31	14										45.00		135.00						45.00		135.00						45.00		135.00																		45.00								45.00				
S4219	001	0		29	10	S4219_001_0	2	5	Specialty Tier	1	3	100000		1	100010110110101000000001				30		90	30		90	1	30		90							30				31	14													341.00	25		25					341.00	25		25					25		25																	25							25			
S4219	001	0		29	10	S4219_001_0	2	4	Non-Preferred Brand	1	3	100000		2	100010110110101000000001				30		90	30		90	1	30		90							30				31	14										95.00		285.00						95.00		285.00						95.00		285.00																		95.00								95.00				
S4219	001	0		29	10	S4219_001_0	2	2	Non-Preferred Generic	1	3	000100		2	000010110110101000000100				30		90	30		90	1	30		90							30		31													25.00		75.00						25.00		75.00						25.00		75.00																		25.00					25.00							
S4219	001	0		29	10	S4219_001_0	2	1	Preferred Generic	1	3	001000		2	000010110110101000000100				30		90	30		90	1	30		90							30		31													0.00		0.00						2.50		7.50						2.50		7.50																		2.50					2.50							
S4802	012	0		29	10	S4802_012_0	2	1	Generic	1	2	010000		2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					6.00	12.00	18.00																													6.00	12.00	18.00					12.00	24.00	36.00				6.00					6.00							
S4802	012	0		29	10	S4802_012_0	2	4	Specialty Tier	1	2	010010		1	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14					145.72	25	25	25																												25	25	25					25	25	25			25				25			25			
S4802	012	0		29	10	S4802_012_0	2	2	Preferred Brand	1	2	000001		2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		35.00	70.00	105.00																													35.00	70.00	105.00					70.00	140.00	210.00				35.00								35.00				
S4802	012	0		29	10	S4802_012_0	2	3	Non-Preferred Brand	1	2	100100		2	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14		79.00	158.00	237.00																													79.00	158.00	237.00					158.00	316.00	474.00				79.00					79.00			79.00				
S4802	013	0		29	10	S4802_013_0	2	4	Specialty Tier	1	2	010010		1	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14					155.25	25	25	25																												25	25	25					25	25	25			25				25			25			
S4802	013	0		29	10	S4802_013_0	2	3	Non-Preferred Brand	1	2	100100		2	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14		80.00	160.00	240.00																													80.00	160.00	240.00					160.00	320.00	480.00				80.00					80.00			80.00				
S4802	013	0		29	10	S4802_013_0	2	2	Preferred Brand	1	2	000001		2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		38.00	76.00	114.00																													38.00	76.00	114.00					76.00	152.00	228.00				38.00								38.00				
S4802	013	0		29	10	S4802_013_0	2	1	Generic	1	2	010000		2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					6.00	12.00	18.00																													6.00	12.00	18.00					12.00	24.00	36.00				6.00					6.00							
S4802	014	0		29	10	S4802_014_0	2	3	Non-Preferred Brand	1	2	100100		2	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14		80.00	160.00	240.00																													80.00	160.00	240.00					160.00	320.00	480.00				80.00					80.00			80.00				
S4802	014	0		29	10	S4802_014_0	2	4	Specialty Tier	1	2	010010		1	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14					153.85	25	25	25																												25	25	25					25	25	25			25				25			25			
S4802	014	0		29	10	S4802_014_0	2	2	Preferred Brand	1	2	000001		2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		38.00	76.00	114.00																													38.00	76.00	114.00					76.00	152.00	228.00				38.00								38.00				
S4802	014	0		29	10	S4802_014_0	2	1	Generic	1	2	010000		2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					6.00	12.00	18.00																													6.00	12.00	18.00					12.00	24.00	36.00				6.00					6.00							
S4802	020	0		29	10	S4802_020_0	2	2	Preferred Brand	1	2	000001		2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		37.00	74.00	111.00																													37.00	74.00	111.00					74.00	148.00	222.00				37.00								37.00				
S4802	020	0		29	10	S4802_020_0	2	3	Non-Preferred Brand	1	2	100100		2	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14		80.00	160.00	240.00																													80.00	160.00	240.00					160.00	320.00	480.00				80.00					80.00			80.00				
S4802	020	0		29	10	S4802_020_0	2	4	Specialty Tier	1	2	010010		1	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14					152.73	25	25	25																												25	25	25					25	25	25			25				25			25			
S4802	020	0		29	10	S4802_020_0	2	1	Generic	1	2	010000		2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					6.00	12.00	18.00																													6.00	12.00	18.00					12.00	24.00	36.00				6.00					6.00							
S4802	021	0		29	10	S4802_021_0	2	4	Specialty Tier	1	2	010010		1	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14					150.58	25	25	25																												25	25	25					25	25	25			25				25			25			
S4802	021	0		29	10	S4802_021_0	2	1	Generic	1	2	010000		2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					6.00	12.00	18.00																													6.00	12.00	18.00					12.00	24.00	36.00				6.00					6.00							
S4802	021	0		29	10	S4802_021_0	2	2	Preferred Brand	1	2	000001		2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		36.00	72.00	108.00																													36.00	72.00	108.00					72.00	144.00	216.00				36.00								36.00				
S4802	021	0		29	10	S4802_021_0	2	3	Non-Preferred Brand	1	2	100100		2	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14		80.00	160.00	240.00																													80.00	160.00	240.00					160.00	320.00	480.00				80.00					80.00			80.00				
S4802	030	0		29	10	S4802_030_0	2	4	Specialty Tier	1	2	010010		1	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14					159.21	25	25	25																												25	25	25					25	25	25			25				25			25			
S4802	030	0		29	10	S4802_030_0	2	3	Non-Preferred Brand	1	2	100100		2	111100000010000111111101	30	60	90							2				30	60	90	30	60	90	30		31		31	14		80.00	160.00	240.00																													80.00	160.00	240.00					160.00	320.00	480.00				80.00					80.00			80.00				
S4802	030	0		29	10	S4802_030_0	2	1	Generic	1	2	010000		2	011100000010000111111100	30	60	90							2				30	60	90	30	60	90	30		31					6.00	12.00	18.00																													6.00	12.00	18.00					12.00	24.00	36.00				6.00					6.00							
S4802	030	0		29	10	S4802_030_0	2	2	Preferred Brand	1	2	000001		2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		40.00	80.00	120.00																													40.00	80.00	120.00					80.00	160.00	240.00				40.00								40.00				
S5540	002	0		29	10	S5540_002_0	4	5	Specialty Tier	1	3	101101		1	111100000010000111111111	30	60	90							2				30	60	90	30	60	90	30		31	14	31	14					29.00	29	29	29																												29	29	29					29	29	29			29				29			29			
S5540	002	0		29	10	S5540_002_0	4	4	Non-Preferred Brand	1	3	100000		2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		95.00	190.00	285.00																													95.00	190.00	237.50					95.00	190.00	285.00				95.00								95.00				
S5540	002	0		29	10	S5540_002_0	4	3	Preferred Brand	1	3	000001		2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		45.00	90.00	135.00																													45.00	90.00	112.50					45.00	90.00	135.00				45.00								45.00				
S5540	002	0		29	10	S5540_002_0	4	2	Non-Preferred Generic	1	3	000100		2	011100000010000111111110	30	60	90							2				30	60	90	30	60	90	30		31	14				25.00	50.00	75.00																													25.00	50.00	62.50					25.00	50.00	75.00				25.00					25.00							
S5540	002	0		29	10	S5540_002_0	4	1	Preferred Generic	1	3	001000		2	011100000010000111111110	30	60	90							2				30	60	90	30	60	90	30		31	14				4.00	8.00	12.00																													0.00	0.00	0.00					4.00	8.00	12.00				4.00					4.00							
S5540	004	0		29	10	S5540_004_0	5	5	Specialty Tier	1	4	101101	1	1	111100000010000111111111	30	60	90							2				30	60	90	30	60	90	30		31	14	31	14					33.00	33	33	33																												33	33	33					33	33	33			33				33			33			
S5540	004	0		29	10	S5540_004_0	5	4	Non-Preferred Brand	1	4	100000	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		70.00	140.00	210.00																													70.00	140.00	175.00					70.00	140.00	210.00				70.00								70.00				
S5540	004	0		29	10	S5540_004_0	5	3	Preferred Brand	1	4	000001	1	2	111100000010000111111001	30	60	90							2				30	60	90	30	60	90	30				31	14		30.00	60.00	90.00																													30.00	60.00	75.00					30.00	60.00	90.00				30.00								30.00				
S5540	004	0		29	10	S5540_004_0	5	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000111111110	30	60	90							2				30	60	90	30	60	90	30		31	14				20.00	40.00	60.00																													20.00	40.00	50.00					20.00	40.00	60.00				20.00					20.00							
S5540	004	0		29	10	S5540_004_0	5	1	Preferred Generic	3	4	001000	1	2	011100000010000111111110	30	60	90							2				30	60	90	30	60	90	30		31	14				4.00	8.00	12.00																													0.00	0.00	0.00					4.00	8.00	12.00				4.00					4.00					1		
S5540	004	0		29	10	S5540_004_0	5	1	Preferred Generic	1	4	001000	1	2	011100000010000111111110	30	60	90							2				30	60	90	30	60	90	30		31	14				4.00	8.00	12.00																													0.00	0.00	0.00					4.00	8.00	12.00				4.00					4.00							
S5552	002	0		29	10	S5552_002_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						10.00		30.00													0.00		0.00					5.00		15.00				10.00					5.00			5.00				
S5552	002	0		29	10	S5552_002_0	2	2	Preferred Brand	1	4	010001	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										41.00		123.00						45.00		135.00													41.00		113.00					41.00		123.00				45.00					41.00			41.00				
S5552	002	0		29	10	S5552_002_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										74.00		222.00						79.00		237.00													74.00		212.00					74.00		222.00				79.00					74.00			74.00				
S5552	002	0		29	10	S5552_002_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													759.00	33							759.00	33														33							33					33				33			33			
S5552	002	0		29	10	S5552_002_0	2	1	Preferred Generic	3	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						10.00		30.00													0.00		0.00					5.00		15.00				10.00					5.00			5.00		1		
S5552	002	0		29	10	S5552_002_0	2	2	Preferred Brand	3	4	010001	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													74.00	50		50					81.00	55		55												50		50					55		55			55				50			50	2	1	
S5552	002	0		29	10	S5552_002_0	2	3	Non-Preferred Brand	3	4	100100	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													133.00	50		50					147.00	55		55												50		50					55		55			55				50			50	2	1	
S5552	003	0		29	10	S5552_003_0	2	4	Non-Preferred Brand	1	4	110000	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										90.00		270.00						90.00		270.00													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
S5552	003	0		29	10	S5552_003_0	2	5	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													674.00	33							663.00	33														33							33					33				33			33			
S5552	003	0		29	10	S5552_003_0	2	3	Preferred Brand	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										45.00		135.00						45.00		135.00													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
S5552	003	0		29	10	S5552_003_0	2	2	Non-Preferred Generic	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						7.00		21.00													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
S5552	003	0		29	10	S5552_003_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										2.00		6.00						5.00		15.00													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
S5552	004	0		29	10	S5552_004_0	4	5	Specialty Tier	1	2	010010		1	100010010010000100100101				30			30							30			30			30		31		31	14													476.00	25							469.00	25														25							25					25				25			25			
S5552	004	0		29	10	S5552_004_0	4	4	Non-Preferred Brand	1	2	110000		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													98.00	33		33					104.00	36		36												33		33					36		36			36				36			36			
S5552	004	0		29	10	S5552_004_0	4	3	Preferred Brand	1	2	000101		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													22.00	20		20					29.00	25		25												20		20					25		25			25				25			25			
S5552	004	0		29	10	S5552_004_0	4	2	Non-Preferred Generic	1	2	000101		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										4.00		12.00						13.00		39.00													0.00		0.00					13.00		39.00				13.00					13.00			13.00				
S5552	004	0		29	10	S5552_004_0	4	1	Preferred Generic	1	2	001010		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										1.00		3.00						10.00		30.00													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
S5569	006	0		29	10	S5569_006_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	2										30		31													0.00		0.00						7.00		21.00																										7.00					7.00							
S5569	006	0		29	10	S5569_006_0	2	2	Preferred Brand	1	4	000001	1	2	100010110110000000000001				30		90	30		90	2										30				31	14										35.00		105.00						45.00		135.00																										45.00								45.00				
S5569	006	0		29	10	S5569_006_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000000000101				30		90	30		90	2										30		31		31	14										70.00		210.00						95.00		285.00																										95.00					95.00			95.00				
S5569	006	0		29	10	S5569_006_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													572.71	33							572.71	33																										33				33			33			
S5569	007	0		29	10	S5569_007_0	3	1	Preferred Generic	1	2	001000		2	000010110110101000000100				30		90	30		90	2	30		90							30		31													1.15		3.45						3.00		9.00						1.15		3.45																		3.00					3.00							
S5569	007	0		29	10	S5569_007_0	3	2	Preferred Brand	1	2	000001		1	100010110110101000000001				30		90	30		90	2	30		90							30				31	14													30.15	20		20					37.69	25		25					20		20																	25							25			
S5569	007	0		29	10	S5569_007_0	3	3	Non-Preferred Brand	1	2	100100		1	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14													52.08	30		30					69.45	40		40					30		30																	40				40			40			
S5580	003	0		29	10	S5580_003_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5580	003	0		29	10	S5580_003_0	2	2	Non-Preferred Generic	1	4	000110	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										7.00		21.00						12.00		36.00								30.00																		12.00					12.00			12.00				
S5580	003	0		29	10	S5580_003_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										40.00		100.00						45.00		113.00								90.00																		45.00					45.00			45.00				
S5580	003	0		29	10	S5580_003_0	2	4	Non-Preferred Brand	1	4	110000	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		238.00						95.00		238.00								190.00																		95.00					95.00			95.00				
S5580	003	0		29	10	S5580_003_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													609.01	29		29					609.01	29		29							29																	29				29			29			
S5580	006	0		29	10	S5580_006_0	2	1	Preferred Generic	1	2	001010		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5580	006	0		29	10	S5580_006_0	2	2	Non-Preferred Generic	1	2	000110		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										4.00		12.00						9.00		27.00								24.00																		9.00					9.00			9.00				
S5580	006	0		29	10	S5580_006_0	2	3	Preferred Brand	1	2	010001		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										40.00		120.00						45.00		135.00								122.00																		45.00					45.00			45.00				
S5580	006	0		29	10	S5580_006_0	2	4	Non-Preferred Brand	1	2	110000		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		285.00						95.00		285.00								257.00																		95.00					95.00			95.00				
S5580	006	0		29	10	S5580_006_0	2	5	Specialty Tier	1	2	010010		1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													550.83	25		25					550.83	25		25							25																	25				25			25			
S5584	001	0		29	10	S5584_001_0	4	1	Preferred Generic	1	3	001000		2	000010110110101000000100				31		90	31		90	1	31		90							31		31													4.00		10.00						4.00		12.00						4.00		10.00																		4.00					4.00							
S5584	001	0		29	10	S5584_001_0	4	5	Specialty Tier	1	3	010010		1	100010010010100000000101				31			31				31									31		31		31	14													483.00	25							483.00	25							25																			25				25			25			
S5584	001	0		29	10	S5584_001_0	4	4	Non-Preferred Brand	1	3	100000		2	100010110110101000000001				31		90	31		90	1	31		90							31				31	14										95.00		237.50						95.00		285.00						95.00		237.50																		95.00							2.74	95.00				
S5584	001	0		29	10	S5584_001_0	4	3	Preferred Brand	1	3	000001		2	100010110110101000000001				31		90	31		90	1	31		90							31				31	14										45.00		112.50						45.00		135.00						45.00		112.50																		45.00							1.45	45.00				
S5584	001	0		29	10	S5584_001_0	4	2	Non-Preferred Generic	1	3	000100		2	000010110110101000000100				31		90	31		90	1	31		90							31		31													15.00		37.50						15.00		45.00						15.00		37.50																		15.00					15.00							
S5584	002	0		29	10	S5584_002_0	4	1	Preferred Generic	1	4	001000	1	2	000010110110101000000100				31		90	31		90	1	31		90							31		31													4.00		10.00						4.00		12.00						4.00		10.00																		4.00					4.00							
S5584	002	0		29	10	S5584_002_0	4	2	Non-Preferred Generic	1	4	000100	1	2	000010110110101000000100				31		90	31		90	1	31		90							31		31													10.00		25.00						10.00		30.00						10.00		25.00																		10.00					10.00							
S5584	002	0		29	10	S5584_002_0	4	1	Preferred Generic	3	4	001000	1	2	000010110110101000000100				31		90	31		90	1	31		90							31		31													4.00		10.00						4.00		12.00						4.00		10.00																		4.00					4.00					1		
S5584	002	0		29	10	S5584_002_0	4	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				31			31				31									31		31		31	14													489.00	30							489.00	30							30																			30				30			30			
S5584	002	0		29	10	S5584_002_0	4	4	Non-Preferred Brand	1	4	100000	1	2	100010110110101000000001				31		90	31		90	1	31		90							31				31	14										85.00		212.50						85.00		255.00						85.00		212.50																		85.00							2.74	85.00				
S5584	002	0		29	10	S5584_002_0	4	3	Preferred Brand	1	4	000001	1	2	100010110110101000000001				31		90	31		90	1	31		90							31				31	14										45.00		112.50						45.00		135.00						45.00		112.50																		45.00							1.45	45.00				
S5584	002	0		29	10	S5584_002_0	4	2	Non-Preferred Generic	3	4	000100	1	2	000010110110101000000100				31		90	31		90	1	31		90							31		31													10.00		25.00						10.00		30.00						10.00		25.00																		10.00					10.00					1		
S5593	002	0		29	10	S5593_002_0	2	4	Non-Preferred Brand	1	3	100000		1	110100000010001000000001	34		90							1			90							34				34	14					78.01	48		48																							48																	48							48			
S5593	002	0		29	10	S5593_002_0	2	5	Specialty Tier	1	3	010010		1	110100000010001000000101	34		90							1			90							34		34		34	14					533.79	26		26																							26																	26				26			26			
S5593	002	0		29	10	S5593_002_0	2	3	Preferred Brand	1	3	000001		1	110100000010001000000001	34		90							1			90							34				34	14					52.47	25		25																							25																	25							25			
S5593	002	0		29	10	S5593_002_0	2	1	Preferred Generic	1	3	001000		2	010100000010001000000100	34		90							1			90							34		34					4.00		12.00																								10.00																		4.00					4.00							
S5593	002	0		29	10	S5593_002_0	2	2	Non-Preferred Generic	1	3	000100		2	010100000010001000000100	34		90							1			90							34		34					12.00		36.00																								30.00																		12.00					12.00							
S5593	003	0		29	10	S5593_003_0	3	4	Specialty Tier	1	4	010010	1	1	110100000010001000000101	34		90							1			90							34		34		34	14					584.84	33		33																							33																	33				33			33			
S5593	003	0		29	10	S5593_003_0	3	2	Preferred Brand	1	4	000001	1	2	110100000010001000000001	34		90							1			90							34				34	14		40.00		120.00																								100.00																		40.00								40.00				
S5593	003	0		29	10	S5593_003_0	3	1	Generic	1	4	010000	1	2	010100000010001000000100	34		90							1			90							34		34					7.00		21.00																								17.50																		7.00					7.00							
S5593	003	0		29	10	S5593_003_0	3	3	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	34		90							1			90							34				34	14		70.00		210.00																								175.00																		70.00								70.00				
S5593	003	0		29	10	S5593_003_0	3	1	Generic	3	4	010000	1	1	010100000010001000000100	34		90							1			90							34		34								20.59	50		50																							50																	50				50				1		
S5596	001	0		29	10	S5596_001_0	3	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00					1		
S5596	001	0		29	10	S5596_001_0	3	5	Injectable Drugs	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					68.64	33	33	33																					33	33	33																	33				33			33			
S5596	001	0		29	10	S5596_001_0	3	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					898.92	33																							33																			33				33			33			
S5596	001	0		29	10	S5596_001_0	3	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		90.00	180.00	270.00																						90.00	225.00	225.00																		90.00					90.00			90.00				
S5596	001	0		29	10	S5596_001_0	3	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	112.50	112.50																		45.00					45.00			45.00				
S5596	001	0		29	10	S5596_001_0	3	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5596	001	0		29	10	S5596_001_0	3	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5596	003	0		29	10	S5596_003_0	4	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5596	003	0		29	10	S5596_003_0	4	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	112.50	112.50																		45.00					45.00			45.00				
S5596	003	0		29	10	S5596_003_0	4	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		90.00	180.00	270.00																						90.00	225.00	225.00																		90.00					90.00			90.00				
S5596	003	0		29	10	S5596_003_0	4	5	Injectable Drugs	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					94.05	33	33	33																					33	33	33																	33				33			33			
S5596	003	0		29	10	S5596_003_0	4	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					878.46	33																							33																			33				33			33			
S5596	003	0		29	10	S5596_003_0	4	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00					1		
S5596	003	0		29	10	S5596_003_0	4	2	Non-Preferred Generic	3	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00					1		
S5596	003	0		29	10	S5596_003_0	4	3	Preferred Brand	3	4	000101	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					91.08	69	69	69																					69	69	69																	69				69			69	2	1	
S5596	003	0		29	10	S5596_003_0	4	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5596	005	0		29	10	S5596_005_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		85.00	170.00	255.00																						85.00	212.50	212.50																		85.00					85.00			85.00				
S5596	005	0		29	10	S5596_005_0	3	3	Preferred Brand	1	2	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		33.00	66.00	99.00																						33.00	82.50	82.50																		33.00					33.00			33.00				
S5596	005	0		29	10	S5596_005_0	3	2	Non-Preferred Generic	1	2	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				6.00	12.00	18.00																						6.00	9.00	9.00																		6.00					6.00							
S5596	005	0		29	10	S5596_005_0	3	1	Preferred Generic	1	2	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5596	005	0		29	10	S5596_005_0	3	5	Injectable Drugs	1	2	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					66.50	25	25	25																					25	25	25																	25				25			25			
S5596	005	0		29	10	S5596_005_0	3	6	Specialty Tier	1	2	010010		1	110000000010100000000111	30										30									30		34	14	34	14					470.75	25																							25																			25				25			25			
S5596	006	0		29	10	S5596_006_0	3	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	112.50	112.50																		45.00					45.00			45.00				
S5596	006	0		29	10	S5596_006_0	3	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		90.00	180.00	270.00																						90.00	225.00	225.00																		90.00					90.00			90.00				
S5596	006	0		29	10	S5596_006_0	3	5	Injectable Drugs	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					90.75	33	33	33																					33	33	33																	33				33			33			
S5596	006	0		29	10	S5596_006_0	3	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5596	006	0		29	10	S5596_006_0	3	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5596	006	0		29	10	S5596_006_0	3	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00					1		
S5596	006	0		29	10	S5596_006_0	3	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					918.39	33																							33																			33				33			33			
S5596	007	0		29	10	S5596_007_0	3	3	Preferred Brand	3	4	000101	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					85.56	69	69	69																					69	69	69																	69				69			69	2	1	
S5596	007	0		29	10	S5596_007_0	3	2	Non-Preferred Generic	3	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00					1		
S5596	007	0		29	10	S5596_007_0	3	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00					1		
S5596	007	0		29	10	S5596_007_0	3	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					974.82	33																							33																			33				33			33			
S5596	007	0		29	10	S5596_007_0	3	5	Injectable Drugs	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					89.43	33	33	33																					33	33	33																	33				33			33			
S5596	007	0		29	10	S5596_007_0	3	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		90.00	180.00	270.00																						90.00	225.00	225.00																		90.00					90.00			90.00				
S5596	007	0		29	10	S5596_007_0	3	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	112.50	112.50																		45.00					45.00			45.00				
S5596	007	0		29	10	S5596_007_0	3	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5596	007	0		29	10	S5596_007_0	3	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5596	009	0		29	10	S5596_009_0	3	6	Specialty Tier	1	2	010010		1	110000000010100000000111	30										30									30		34	14	34	14					444.25	25																							25																			25				25			25			
S5596	009	0		29	10	S5596_009_0	3	5	Injectable Drugs	1	2	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					85.75	25	25	25																					25	25	25																	25				25			25			
S5596	009	0		29	10	S5596_009_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		85.00	170.00	255.00																						85.00	212.50	212.50																		85.00					85.00			85.00				
S5596	009	0		29	10	S5596_009_0	3	3	Preferred Brand	1	2	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		34.00	68.00	102.00																						34.00	85.00	85.00																		34.00					34.00			34.00				
S5596	009	0		29	10	S5596_009_0	3	1	Preferred Generic	1	2	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5596	009	0		29	10	S5596_009_0	3	2	Non-Preferred Generic	1	2	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				6.00	12.00	18.00																						6.00	9.00	9.00																		6.00					6.00							
S5596	010	0		29	10	S5596_010_0	3	5	Injectable Drugs	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					83.49	33	33	33																					33	33	33																	33				33			33			
S5596	010	0		29	10	S5596_010_0	3	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		90.00	180.00	270.00																						90.00	225.00	225.00																		90.00					90.00			90.00				
S5596	010	0		29	10	S5596_010_0	3	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	112.50	112.50																		45.00					45.00			45.00				
S5596	010	0		29	10	S5596_010_0	3	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5596	010	0		29	10	S5596_010_0	3	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5596	010	0		29	10	S5596_010_0	3	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					953.70	33																							33																			33				33			33			
S5596	010	0		29	10	S5596_010_0	3	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00					1		
S5596	011	0		29	10	S5596_011_0	3	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5596	011	0		29	10	S5596_011_0	3	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5596	011	0		29	10	S5596_011_0	3	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	112.50	112.50																		45.00					45.00			45.00				
S5596	011	0		29	10	S5596_011_0	3	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		90.00	180.00	270.00																						90.00	225.00	225.00																		90.00					90.00			90.00				
S5596	011	0		29	10	S5596_011_0	3	5	Injectable Drugs	1	4	010010	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	237.50	237.50																		95.00					95.00			95.00				
S5596	011	0		29	10	S5596_011_0	3	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					820.38	33																							33																			33				33			33			
S5596	011	0		29	10	S5596_011_0	3	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00					1		
S5596	011	0		29	10	S5596_011_0	3	2	Non-Preferred Generic	3	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00					1		
S5596	011	0		29	10	S5596_011_0	3	3	Preferred Brand	3	4	000101	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					87.63	69	69	69																					69	69	69																	69				69			69	2	1	
S5596	013	0		29	10	S5596_013_0	3	5	Injectable Drugs	1	2	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					96.50	25	25	25																					25	25	25																	25				25			25			
S5596	013	0		29	10	S5596_013_0	3	6	Specialty Tier	1	2	010010		1	110000000010100000000111	30										30									30		34	14	34	14					498.00	25																							25																			25				25			25			
S5596	013	0		29	10	S5596_013_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		85.00	170.00	255.00																						85.00	212.50	212.50																		85.00					85.00			85.00				
S5596	013	0		29	10	S5596_013_0	3	3	Preferred Brand	1	2	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		36.00	72.00	108.00																						36.00	90.00	90.00																		36.00					36.00			36.00				
S5596	013	0		29	10	S5596_013_0	3	2	Non-Preferred Generic	1	2	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				6.00	12.00	18.00																						6.00	9.00	9.00																		6.00					6.00							
S5596	013	0		29	10	S5596_013_0	3	1	Preferred Generic	1	2	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5596	014	0		29	10	S5596_014_0	3	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00					1		
S5596	014	0		29	10	S5596_014_0	3	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					790.68	33																							33																			33				33			33			
S5596	014	0		29	10	S5596_014_0	3	5	Injectable Drugs	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					75.90	33	33	33																					33	33	33																	33				33			33			
S5596	014	0		29	10	S5596_014_0	3	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		90.00	180.00	270.00																						90.00	225.00	225.00																		90.00					90.00			90.00				
S5596	014	0		29	10	S5596_014_0	3	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	112.50	112.50																		45.00					45.00			45.00				
S5596	014	0		29	10	S5596_014_0	3	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5596	014	0		29	10	S5596_014_0	3	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5596	015	0		29	10	S5596_015_0	3	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	112.50	112.50																		45.00					45.00			45.00				
S5596	015	0		29	10	S5596_015_0	3	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5596	015	0		29	10	S5596_015_0	3	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5596	015	0		29	10	S5596_015_0	3	5	Injectable Drugs	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					77.55	33	33	33																					33	33	33																	33				33			33			
S5596	015	0		29	10	S5596_015_0	3	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		90.00	180.00	270.00																						90.00	225.00	225.00																		90.00					90.00			90.00				
S5596	015	0		29	10	S5596_015_0	3	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00					1		
S5596	015	0		29	10	S5596_015_0	3	2	Non-Preferred Generic	3	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00					1		
S5596	015	0		29	10	S5596_015_0	3	3	Preferred Brand	3	4	000101	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					90.39	69	69	69																					69	69	69																	69				69			69	2	1	
S5596	015	0		29	10	S5596_015_0	3	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					663.63	33																							33																			33				33			33			
S5596	017	0		29	10	S5596_017_0	3	5	Injectable Drugs	1	2	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					74.25	25	25	25																					25	25	25																	25				25			25			
S5596	017	0		29	10	S5596_017_0	3	6	Specialty Tier	1	2	010010		1	110000000010100000000111	30										30									30		34	14	34	14					474.25	25																							25																			25				25			25			
S5596	017	0		29	10	S5596_017_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		85.00	170.00	255.00																						85.00	212.50	212.50																		85.00					85.00			85.00				
S5596	017	0		29	10	S5596_017_0	3	3	Preferred Brand	1	2	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		35.00	70.00	105.00																						35.00	87.50	87.50																		35.00					35.00			35.00				
S5596	017	0		29	10	S5596_017_0	3	2	Non-Preferred Generic	1	2	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				6.00	12.00	18.00																						6.00	9.00	9.00																		6.00					6.00							
S5596	017	0		29	10	S5596_017_0	3	1	Preferred Generic	1	2	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5596	018	0		29	10	S5596_018_0	3	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					894.96	33																							33																			33				33			33			
S5596	018	0		29	10	S5596_018_0	3	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00					1		
S5596	018	0		29	10	S5596_018_0	3	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		90.00	180.00	270.00																						90.00	225.00	225.00																		90.00					90.00			90.00				
S5596	018	0		29	10	S5596_018_0	3	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	112.50	112.50																		45.00					45.00			45.00				
S5596	018	0		29	10	S5596_018_0	3	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5596	018	0		29	10	S5596_018_0	3	5	Injectable Drugs	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					84.48	33	33	33																					33	33	33																	33				33			33			
S5596	018	0		29	10	S5596_018_0	3	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5596	019	0		29	10	S5596_019_0	3	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5596	019	0		29	10	S5596_019_0	3	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5596	019	0		29	10	S5596_019_0	3	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	112.50	112.50																		45.00					45.00			45.00				
S5596	019	0		29	10	S5596_019_0	3	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		90.00	180.00	270.00																						90.00	225.00	225.00																		90.00					90.00			90.00				
S5596	019	0		29	10	S5596_019_0	3	5	Injectable Drugs	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					68.31	33	33	33																					33	33	33																	33				33			33			
S5596	019	0		29	10	S5596_019_0	3	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					776.49	33																							33																			33				33			33			
S5596	019	0		29	10	S5596_019_0	3	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00					1		
S5596	019	0		29	10	S5596_019_0	3	2	Non-Preferred Generic	3	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00					1		
S5596	019	0		29	10	S5596_019_0	3	3	Preferred Brand	3	4	000101	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					90.39	69	69	69																					69	69	69																	69				69			69	2	1	
S5596	033	0		29	10	S5596_033_0	5	1	Preferred Generic	1	2	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5596	033	0		29	10	S5596_033_0	5	2	Non-Preferred Generic	1	2	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				6.00	12.00	18.00																						6.00	9.00	9.00																		6.00					6.00							
S5596	033	0		29	10	S5596_033_0	5	3	Preferred Brand	1	2	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		39.00	78.00	117.00																						39.00	97.50	97.50																		39.00					39.00			39.00				
S5596	033	0		29	10	S5596_033_0	5	4	Non-Preferred Brand	1	2	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		85.00	170.00	255.00																						85.00	212.50	212.50																		85.00					85.00			85.00				
S5596	033	0		29	10	S5596_033_0	5	5	Injectable Drugs	1	2	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					102.00	25	25	25																					25	25	25																	25				25			25			
S5596	033	0		29	10	S5596_033_0	5	6	Specialty Tier	1	2	010010		1	110000000010100000000111	30										30									30		34	14	34	14					452.75	25																							25																			25				25			25			
S5596	034	0		29	10	S5596_034_0	5	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00					1		
S5596	034	0		29	10	S5596_034_0	5	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					808.17	33																							33																			33				33			33			
S5596	034	0		29	10	S5596_034_0	5	5	Injectable Drugs	1	4	010010	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	237.50	237.50																		95.00					95.00			95.00				
S5596	034	0		29	10	S5596_034_0	5	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		90.00	180.00	270.00																						90.00	225.00	225.00																		90.00					90.00			90.00				
S5596	034	0		29	10	S5596_034_0	5	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	112.50	112.50																		45.00					45.00			45.00				
S5596	034	0		29	10	S5596_034_0	5	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5596	034	0		29	10	S5596_034_0	5	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5596	035	0		29	10	S5596_035_0	5	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00					1		
S5596	035	0		29	10	S5596_035_0	5	2	Non-Preferred Generic	3	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00					1		
S5596	035	0		29	10	S5596_035_0	5	3	Preferred Brand	3	4	000101	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					85.56	69	69	69																					69	69	69																	69				69			69	2	1	
S5596	035	0		29	10	S5596_035_0	5	5	Injectable Drugs	1	4	010010	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	237.50	237.50																		95.00					95.00			95.00				
S5596	035	0		29	10	S5596_035_0	5	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					817.08	33																							33																			33				33			33			
S5596	035	0		29	10	S5596_035_0	5	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	112.50	112.50																		45.00					45.00			45.00				
S5596	035	0		29	10	S5596_035_0	5	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5596	035	0		29	10	S5596_035_0	5	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5596	035	0		29	10	S5596_035_0	5	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		90.00	180.00	270.00																						90.00	225.00	225.00																		90.00					90.00			90.00				
S5596	043	0		29	10	S5596_043_0	4	6	Specialty Tier	1	2	010010		1	110000000010100000000111	30										30									30		34	14	34	14					588.50	25																							25																			25				25			25			
S5596	043	0		29	10	S5596_043_0	4	5	Injectable Drugs	1	2	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					98.50	25	25	25																					25	25	25																	25				25			25			
S5596	043	0		29	10	S5596_043_0	4	4	Non-Preferred Brand	1	2	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		85.00	170.00	255.00																						85.00	212.50	212.50																		85.00					85.00			85.00				
S5596	043	0		29	10	S5596_043_0	4	3	Preferred Brand	1	2	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		31.00	62.00	93.00																						31.00	77.50	77.50																		31.00					31.00			31.00				
S5596	043	0		29	10	S5596_043_0	4	2	Non-Preferred Generic	1	2	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				6.00	12.00	18.00																						6.00	9.00	9.00																		6.00					6.00							
S5596	043	0		29	10	S5596_043_0	4	1	Preferred Generic	1	2	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5596	044	0		29	10	S5596_044_0	3	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					960.30	33																							33																			33				33			33			
S5596	044	0		29	10	S5596_044_0	3	5	Injectable Drugs	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					72.27	33	33	33																					33	33	33																	33				33			33			
S5596	044	0		29	10	S5596_044_0	3	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		90.00	180.00	270.00																						90.00	225.00	225.00																		90.00					90.00			90.00				
S5596	044	0		29	10	S5596_044_0	3	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	112.50	112.50																		45.00					45.00			45.00				
S5596	044	0		29	10	S5596_044_0	3	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5596	044	0		29	10	S5596_044_0	3	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00					1		
S5596	044	0		29	10	S5596_044_0	3	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5596	045	0		29	10	S5596_045_0	3	2	Non-Preferred Generic	3	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00					1		
S5596	045	0		29	10	S5596_045_0	3	3	Preferred Brand	3	4	000101	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					88.32	69	69	69																					69	69	69																	69				69			69	2	1	
S5596	045	0		29	10	S5596_045_0	3	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00					1		
S5596	045	0		29	10	S5596_045_0	3	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					816.75	33																							33																			33				33			33			
S5596	045	0		29	10	S5596_045_0	3	5	Injectable Drugs	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					73.26	33	33	33																					33	33	33																	33				33			33			
S5596	045	0		29	10	S5596_045_0	3	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		90.00	180.00	270.00																						90.00	225.00	225.00																		90.00					90.00			90.00				
S5596	045	0		29	10	S5596_045_0	3	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5596	045	0		29	10	S5596_045_0	3	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5596	045	0		29	10	S5596_045_0	3	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	112.50	112.50																		45.00					45.00			45.00				
S5596	046	0		29	10	S5596_046_0	3	6	Specialty Tier	1	2	010010		1	110000000010100000000111	30										30									30		34	14	34	14					555.75	25																							25																			25				25			25			
S5596	046	0		29	10	S5596_046_0	3	5	Injectable Drugs	1	2	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					63.50	25	25	25																					25	25	25																	25				25			25			
S5596	046	0		29	10	S5596_046_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		85.00	170.00	255.00																						85.00	212.50	212.50																		85.00					85.00			85.00				
S5596	046	0		29	10	S5596_046_0	3	3	Preferred Brand	1	2	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		44.00	88.00	132.00																						44.00	110.00	110.00																		44.00					44.00			44.00				
S5596	046	0		29	10	S5596_046_0	3	2	Non-Preferred Generic	1	2	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5596	046	0		29	10	S5596_046_0	3	1	Preferred Generic	1	2	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5596	056	0		29	10	S5596_056_0	3	6	Specialty Tier	1	2	010010		1	110000000010100000000111	30										30									30		34	14	34	14					551.00	25																							25																			25				25			25			
S5596	056	0		29	10	S5596_056_0	3	5	Injectable Drugs	1	2	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					69.00	25	25	25																					25	25	25																	25				25			25			
S5596	056	0		29	10	S5596_056_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		85.00	170.00	255.00																						85.00	212.50	212.50																		85.00					85.00			85.00				
S5596	056	0		29	10	S5596_056_0	3	3	Preferred Brand	1	2	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		39.00	78.00	117.00																						39.00	97.50	97.50																		39.00					39.00			39.00				
S5596	056	0		29	10	S5596_056_0	3	2	Non-Preferred Generic	1	2	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				6.00	12.00	18.00																						6.00	9.00	9.00																		6.00					6.00							
S5596	056	0		29	10	S5596_056_0	3	1	Preferred Generic	1	2	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5596	057	0		29	10	S5596_057_0	3	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					832.92	33																							33																			33				33			33			
S5596	057	0		29	10	S5596_057_0	3	5	Injectable Drugs	1	4	010010	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	237.50	237.50																		95.00					95.00			95.00				
S5596	057	0		29	10	S5596_057_0	3	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		90.00	180.00	270.00																						90.00	225.00	225.00																		90.00					90.00			90.00				
S5596	057	0		29	10	S5596_057_0	3	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	112.50	112.50																		45.00					45.00			45.00				
S5596	057	0		29	10	S5596_057_0	3	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5596	057	0		29	10	S5596_057_0	3	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00					1		
S5596	057	0		29	10	S5596_057_0	3	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5596	058	0		29	10	S5596_058_0	3	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5596	058	0		29	10	S5596_058_0	3	3	Preferred Brand	3	4	000101	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					91.77	69	69	69																					69	69	69																	69				69			69	2	1	
S5596	058	0		29	10	S5596_058_0	3	2	Non-Preferred Generic	3	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00					1		
S5596	058	0		29	10	S5596_058_0	3	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00					1		
S5596	058	0		29	10	S5596_058_0	3	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					746.13	33																							33																			33				33			33			
S5596	058	0		29	10	S5596_058_0	3	5	Injectable Drugs	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					100.65	33	33	33																					33	33	33																	33				33			33			
S5596	058	0		29	10	S5596_058_0	3	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5596	058	0		29	10	S5596_058_0	3	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	112.50	112.50																		45.00					45.00			45.00				
S5596	058	0		29	10	S5596_058_0	3	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		90.00	180.00	270.00																						90.00	225.00	225.00																		90.00					90.00			90.00				
S5596	059	0		29	10	S5596_059_0	3	2	Non-Preferred Generic	1	2	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				6.00	12.00	18.00																						6.00	9.00	9.00																		6.00					6.00							
S5596	059	0		29	10	S5596_059_0	3	1	Preferred Generic	1	2	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5596	059	0		29	10	S5596_059_0	3	5	Injectable Drugs	1	2	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					81.50	25	25	25																					25	25	25																	25				25			25			
S5596	059	0		29	10	S5596_059_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		85.00	170.00	255.00																						85.00	212.50	212.50																		85.00					85.00			85.00				
S5596	059	0		29	10	S5596_059_0	3	3	Preferred Brand	1	2	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		42.00	84.00	126.00																						42.00	105.00	105.00																		42.00					42.00			42.00				
S5596	059	0		29	10	S5596_059_0	3	6	Specialty Tier	1	2	010010		1	110000000010100000000111	30										30									30		34	14	34	14					444.50	25																							25																			25				25			25			
S5596	060	0		29	10	S5596_060_0	3	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	112.50	112.50																		45.00					45.00			45.00				
S5596	060	0		29	10	S5596_060_0	3	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5596	060	0		29	10	S5596_060_0	3	5	Injectable Drugs	1	4	010010	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	237.50	237.50																		95.00					95.00			95.00				
S5596	060	0		29	10	S5596_060_0	3	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					960.63	33																							33																			33				33			33			
S5596	060	0		29	10	S5596_060_0	3	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00					1		
S5596	060	0		29	10	S5596_060_0	3	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		90.00	180.00	270.00																						90.00	225.00	225.00																		90.00					90.00			90.00				
S5596	060	0		29	10	S5596_060_0	3	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5596	061	0		29	10	S5596_061_0	3	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	112.50	112.50																		45.00					45.00			45.00				
S5596	061	0		29	10	S5596_061_0	3	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5596	061	0		29	10	S5596_061_0	3	5	Injectable Drugs	1	4	010010	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	237.50	237.50																		95.00					95.00			95.00				
S5596	061	0		29	10	S5596_061_0	3	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					845.79	33																							33																			33				33			33			
S5596	061	0		29	10	S5596_061_0	3	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00					1		
S5596	061	0		29	10	S5596_061_0	3	2	Non-Preferred Generic	3	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00					1		
S5596	061	0		29	10	S5596_061_0	3	3	Preferred Brand	3	4	000101	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					89.70	69	69	69																					69	69	69																	69				69			69	2	1	
S5596	061	0		29	10	S5596_061_0	3	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		90.00	180.00	270.00																						90.00	225.00	225.00																		90.00					90.00			90.00				
S5596	061	0		29	10	S5596_061_0	3	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5596	062	0		29	10	S5596_062_0	3	3	Preferred Brand	1	2	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	112.50	112.50																		45.00					45.00			45.00				
S5596	062	0		29	10	S5596_062_0	3	1	Preferred Generic	1	2	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5596	062	0		29	10	S5596_062_0	3	5	Injectable Drugs	1	2	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					97.50	25	25	25																					25	25	25																	25				25			25			
S5596	062	0		29	10	S5596_062_0	3	6	Specialty Tier	1	2	010010		1	110000000010100000000111	30										30									30		34	14	34	14					483.25	25																							25																			25				25			25			
S5596	062	0		29	10	S5596_062_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		85.00	170.00	255.00																						85.00	212.50	212.50																		85.00					85.00			85.00				
S5596	062	0		29	10	S5596_062_0	3	2	Non-Preferred Generic	1	2	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				6.00	12.00	18.00																						6.00	9.00	9.00																		6.00					6.00							
S5596	063	0		29	10	S5596_063_0	3	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	112.50	112.50																		45.00					45.00			45.00				
S5596	063	0		29	10	S5596_063_0	3	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5596	063	0		29	10	S5596_063_0	3	5	Injectable Drugs	1	4	010010	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		95.00	190.00	285.00																						95.00	237.50	237.50																		95.00					95.00			95.00				
S5596	063	0		29	10	S5596_063_0	3	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					796.62	33																							33																			33				33			33			
S5596	063	0		29	10	S5596_063_0	3	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00					1		
S5596	063	0		29	10	S5596_063_0	3	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		90.00	180.00	270.00																						90.00	225.00	225.00																		90.00					90.00			90.00				
S5596	063	0		29	10	S5596_063_0	3	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5596	064	0		29	10	S5596_064_0	3	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	112.50	112.50																		45.00					45.00			45.00				
S5596	064	0		29	10	S5596_064_0	3	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		90.00	180.00	270.00																						90.00	225.00	225.00																		90.00					90.00			90.00				
S5596	064	0		29	10	S5596_064_0	3	5	Injectable Drugs	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					41.25	33	33	33																					33	33	33																	33				33			33			
S5596	064	0		29	10	S5596_064_0	3	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					850.74	33																							33																			33				33			33			
S5596	064	0		29	10	S5596_064_0	3	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5596	064	0		29	10	S5596_064_0	3	2	Non-Preferred Generic	3	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00					1		
S5596	064	0		29	10	S5596_064_0	3	3	Preferred Brand	3	4	000101	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					95.91	69	69	69																					69	69	69																	69				69			69	2	1	
S5596	064	0		29	10	S5596_064_0	3	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5596	064	0		29	10	S5596_064_0	3	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00					1		
S5601	002	0		29	10	S5601_002_0	3	3	Non-Preferred Brand	1	2	100100		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					92.71	43	43	43																							43																	43				43			43			
S5601	002	0		29	10	S5601_002_0	3	2	Preferred Brand	1	2	000101		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					22.46	22	22	22																							22																	22				22			22			
S5601	002	0		29	10	S5601_002_0	3	1	Generic	1	2	010001		2	111100000010001000000101	30	60	90							1			90							30		34		34	14		2.00	4.00	5.00																								5.00																		2.00					2.00			2.00				
S5601	002	0		29	10	S5601_002_0	3	4	Specialty Tier	1	2	010010		1	111100000010001000000101	30	60	90							2			90							30		34		34	14					400.93	25	25	25																							25																	25				25			25			
S5601	003	0		29	10	S5601_003_0	3	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	003	0		29	10	S5601_003_0	3	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	003	0		29	10	S5601_003_0	3	2	Preferred Brand	3	4	000101	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													57.07	30	30	30					66.58	35	35	35							30																	35				35			35	1		
S5601	003	0		29	10	S5601_003_0	3	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													63.65	35	35	35					81.83	45	45	45							35																	45				45			45			
S5601	003	0		29	10	S5601_003_0	3	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													390.53	33	33	33					390.53	33	33	33							33																	33				33			33			
S5601	003	0		29	10	S5601_003_0	3	1	Generic	3	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00		1		
S5601	004	0		29	10	S5601_004_0	1	4	Specialty Tier	1	2	010010		1	111100000010001000000101	30	60	90							2			90							30		34		34	14					377.21	25	25	25																							25																	25				25			25			
S5601	004	0		29	10	S5601_004_0	1	3	Non-Preferred Brand	1	2	100100		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					91.37	43	43	43																							43																	43				43			43			
S5601	004	0		29	10	S5601_004_0	1	2	Preferred Brand	1	2	000101		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					22.78	22	22	22																							22																	22				22			22			
S5601	004	0		29	10	S5601_004_0	1	1	Generic	1	2	010001		2	111100000010001000000101	30	60	90							1			90							30		34		34	14		2.00	4.00	5.00																								5.00																		2.00					2.00			2.00				
S5601	005	0		29	10	S5601_005_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													469.80	33	33	33					469.80	33	33	33							33																	33				33			33			
S5601	005	0		29	10	S5601_005_0	1	2	Preferred Brand	3	4	000101	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													56.81	30	30	30					66.28	35	35	35							30																	35				35			35	1		
S5601	005	0		29	10	S5601_005_0	1	1	Generic	3	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00		1		
S5601	005	0		29	10	S5601_005_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													67.81	35	35	35					87.18	45	45	45							35																	45				45			45			
S5601	005	0		29	10	S5601_005_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	005	0		29	10	S5601_005_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	006	0		29	10	S5601_006_0	1	3	Non-Preferred Brand	1	2	100100		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					91.22	43	43	43																							43																	43				43			43			
S5601	006	0		29	10	S5601_006_0	1	2	Preferred Brand	1	2	000101		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					24.93	22	22	22																							22																	22				22			22			
S5601	006	0		29	10	S5601_006_0	1	1	Generic	1	2	010001		2	111100000010001000000101	30	60	90							1			90							30		34		34	14		2.00	4.00	5.00																								5.00																		2.00					2.00			2.00				
S5601	006	0		29	10	S5601_006_0	1	4	Specialty Tier	1	2	010010		1	111100000010001000000101	30	60	90							2			90							30		34		34	14					381.42	25	25	25																							25																	25				25			25			
S5601	007	0		29	10	S5601_007_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	007	0		29	10	S5601_007_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													507.70	33	33	33					507.70	33	33	33							33																	33				33			33			
S5601	007	0		29	10	S5601_007_0	1	2	Preferred Brand	3	4	000101	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													55.88	30	30	30					65.20	35	35	35							30																	35				35			35	1		
S5601	007	0		29	10	S5601_007_0	1	1	Generic	3	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00		1		
S5601	007	0		29	10	S5601_007_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	007	0		29	10	S5601_007_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													67.83	35	35	35					87.21	45	45	45							35																	45				45			45			
S5601	008	0		29	10	S5601_008_0	1	2	Preferred Brand	1	2	000101		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					23.89	21	21	21																							21																	21				21			21			
S5601	008	0		29	10	S5601_008_0	1	3	Non-Preferred Brand	1	2	100100		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					80.99	42	42	42																							42																	42				42			42			
S5601	008	0		29	10	S5601_008_0	1	1	Generic	1	2	010001		2	111100000010001000000101	30	60	90							1			90							30		34		34	14		2.00	4.00	5.00																								5.00																		2.00					2.00			2.00				
S5601	008	0		29	10	S5601_008_0	1	4	Specialty Tier	1	2	010010		1	111100000010001000000101	30	60	90							2			90							30		34		34	14					394.62	25	25	25																							25																	25				25			25			
S5601	009	0		29	10	S5601_009_0	1	1	Generic	3	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00		1		
S5601	009	0		29	10	S5601_009_0	1	2	Preferred Brand	3	4	000101	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													54.56	30	30	30					63.65	35	35	35							30																	35				35			35	1		
S5601	009	0		29	10	S5601_009_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													523.40	33	33	33					523.40	33	33	33							33																	33				33			33			
S5601	009	0		29	10	S5601_009_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													66.48	35	35	35					85.48	45	45	45							35																	45				45			45			
S5601	009	0		29	10	S5601_009_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	009	0		29	10	S5601_009_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	010	0		29	10	S5601_010_0	1	2	Preferred Brand	1	2	000101		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					26.24	23	23	23																							23																	23				23			23			
S5601	010	0		29	10	S5601_010_0	1	1	Generic	1	2	010001		2	111100000010001000000101	30	60	90							1			90							30		34		34	14		2.00	4.00	5.00																								5.00																		2.00					2.00			2.00				
S5601	010	0		29	10	S5601_010_0	1	4	Specialty Tier	1	2	010010		1	111100000010001000000101	30	60	90							2			90							30		34		34	14					365.51	25	25	25																							25																	25				25			25			
S5601	010	0		29	10	S5601_010_0	1	3	Non-Preferred Brand	1	2	100100		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					95.67	45	45	45																							45																	45				45			45			
S5601	011	0		29	10	S5601_011_0	1	1	Generic	3	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00		1		
S5601	011	0		29	10	S5601_011_0	1	2	Preferred Brand	3	4	000101	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													54.96	30	30	30					64.12	35	35	35							30																	35				35			35	1		
S5601	011	0		29	10	S5601_011_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	011	0		29	10	S5601_011_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													64.37	35	35	35					82.76	45	45	45							35																	45				45			45			
S5601	011	0		29	10	S5601_011_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	011	0		29	10	S5601_011_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													468.58	33	33	33					468.58	33	33	33							33																	33				33			33			
S5601	012	0		29	10	S5601_012_0	1	2	Preferred Brand	1	2	000101		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					24.41	23	23	23																							23																	23				23			23			
S5601	012	0		29	10	S5601_012_0	1	3	Non-Preferred Brand	1	2	100100		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					89.30	45	45	45																							45																	45				45			45			
S5601	012	0		29	10	S5601_012_0	1	1	Generic	1	2	010001		2	111100000010001000000101	30	60	90							1			90							30		34		34	14		2.00	4.00	5.00																								5.00																		2.00					2.00			2.00				
S5601	012	0		29	10	S5601_012_0	1	4	Specialty Tier	1	2	010010		1	111100000010001000000101	30	60	90							2			90							30		34		34	14					379.64	25	25	25																							25																	25				25			25			
S5601	013	0		29	10	S5601_013_0	1	2	Preferred Brand	3	4	000101	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													51.92	30	30	30					60.57	35	35	35							30																	35				35			35	1		
S5601	013	0		29	10	S5601_013_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	013	0		29	10	S5601_013_0	1	1	Generic	3	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00		1		
S5601	013	0		29	10	S5601_013_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													483.65	33	33	33					483.65	33	33	33							33																	33				33			33			
S5601	013	0		29	10	S5601_013_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													64.07	35	35	35					82.37	45	45	45							35																	45				45			45			
S5601	013	0		29	10	S5601_013_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	014	0		29	10	S5601_014_0	1	1	Generic	1	2	010001		2	111100000010001000000101	30	60	90							1			90							30		34		34	14		2.00	4.00	5.00																								5.00																		2.00					2.00			2.00				
S5601	014	0		29	10	S5601_014_0	1	4	Specialty Tier	1	2	010010		1	111100000010001000000101	30	60	90							2			90							30		34		34	14					375.38	25	25	25																							25																	25				25			25			
S5601	014	0		29	10	S5601_014_0	1	3	Non-Preferred Brand	1	2	100100		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					90.72	45	45	45																							45																	45				45			45			
S5601	014	0		29	10	S5601_014_0	1	2	Preferred Brand	1	2	000101		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					25.66	23	23	23																							23																	23				23			23			
S5601	015	0		29	10	S5601_015_0	1	2	Preferred Brand	3	4	000101	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													53.12	30	30	30					61.98	35	35	35							30																	35				35			35	1		
S5601	015	0		29	10	S5601_015_0	1	1	Generic	3	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00		1		
S5601	015	0		29	10	S5601_015_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													458.15	33	33	33					458.15	33	33	33							33																	33				33			33			
S5601	015	0		29	10	S5601_015_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	015	0		29	10	S5601_015_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	015	0		29	10	S5601_015_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													64.07	35	35	35					82.38	45	45	45							35																	45				45			45			
S5601	016	0		29	10	S5601_016_0	1	3	Non-Preferred Brand	1	2	100100		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					90.36	45	45	45																							45																	45				45			45			
S5601	016	0		29	10	S5601_016_0	1	4	Specialty Tier	1	2	010010		1	111100000010001000000101	30	60	90							2			90							30		34		34	14					381.04	25	25	25																							25																	25				25			25			
S5601	016	0		29	10	S5601_016_0	1	2	Preferred Brand	1	2	000101		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					28.54	25	25	25																							25																	25				25			25			
S5601	016	0		29	10	S5601_016_0	1	1	Generic	1	2	010001		2	111100000010001000000101	30	60	90							1			90							30		34		34	14		2.00	4.00	5.00																								5.00																		2.00					2.00			2.00				
S5601	017	0		29	10	S5601_017_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													61.78	35	35	35					79.43	45	45	45							35																	45				45			45			
S5601	017	0		29	10	S5601_017_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	017	0		29	10	S5601_017_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	017	0		29	10	S5601_017_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													496.82	33	33	33					496.82	33	33	33							33																	33				33			33			
S5601	017	0		29	10	S5601_017_0	1	1	Generic	3	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00		1		
S5601	017	0		29	10	S5601_017_0	1	2	Preferred Brand	3	4	000101	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													51.56	30	30	30					60.15	35	35	35							30																	35				35			35	1		
S5601	018	0		29	10	S5601_018_0	1	1	Generic	1	2	010001		2	111100000010001000000101	30	60	90							1			90							30		34		34	14		2.00	4.00	5.00																								5.00																		2.00					2.00			2.00				
S5601	018	0		29	10	S5601_018_0	1	2	Preferred Brand	1	2	000101		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					26.11	24	24	24																							24																	24				24			24			
S5601	018	0		29	10	S5601_018_0	1	3	Non-Preferred Brand	1	2	100100		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					91.05	45	45	45																							45																	45				45			45			
S5601	018	0		29	10	S5601_018_0	1	4	Specialty Tier	1	2	010010		1	111100000010001000000101	30	60	90							2			90							30		34		34	14					398.98	25	25	25																							25																	25				25			25			
S5601	019	0		29	10	S5601_019_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													452.93	33	33	33					452.93	33	33	33							33																	33				33			33			
S5601	019	0		29	10	S5601_019_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	019	0		29	10	S5601_019_0	1	1	Generic	3	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00		1		
S5601	019	0		29	10	S5601_019_0	1	2	Preferred Brand	3	4	000101	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													49.78	30	30	30					58.08	35	35	35							30																	35				35			35	1		
S5601	019	0		29	10	S5601_019_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													62.19	35	35	35					79.96	45	45	45							35																	45				45			45			
S5601	019	0		29	10	S5601_019_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	020	0		29	10	S5601_020_0	1	2	Preferred Brand	1	2	000101		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					27.08	25	25	25																							25																	25				25			25			
S5601	020	0		29	10	S5601_020_0	1	4	Specialty Tier	1	2	010010		1	111100000010001000000101	30	60	90							2			90							30		34		34	14					371.66	25	25	25																							25																	25				25			25			
S5601	020	0		29	10	S5601_020_0	1	3	Non-Preferred Brand	1	2	100100		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					91.34	47	47	47																							47																	47				47			47			
S5601	020	0		29	10	S5601_020_0	1	1	Generic	1	2	010001		2	111100000010001000000101	30	60	90							1			90							30		34		34	14		2.00	4.00	5.00																								5.00																		2.00					2.00			2.00				
S5601	021	0		29	10	S5601_021_0	1	1	Generic	3	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00		1		
S5601	021	0		29	10	S5601_021_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													534.29	33	33	33					534.29	33	33	33							33																	33				33			33			
S5601	021	0		29	10	S5601_021_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													64.30	35	35	35					82.67	45	45	45							35																	45				45			45			
S5601	021	0		29	10	S5601_021_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	021	0		29	10	S5601_021_0	1	2	Preferred Brand	3	4	000101	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													47.08	30	30	30					54.93	35	35	35							30																	35				35			35	1		
S5601	021	0		29	10	S5601_021_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	022	0		29	10	S5601_022_0	1	2	Preferred Brand	1	2	000101		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					24.84	23	23	23																							23																	23				23			23			
S5601	022	0		29	10	S5601_022_0	1	1	Generic	1	2	010001		2	111100000010001000000101	30	60	90							1			90							30		34		34	14		2.00	4.00	5.00																								5.00																		2.00					2.00			2.00				
S5601	022	0		29	10	S5601_022_0	1	3	Non-Preferred Brand	1	2	100100		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					88.01	43	43	43																							43																	43				43			43			
S5601	022	0		29	10	S5601_022_0	1	4	Specialty Tier	1	2	010010		1	111100000010001000000101	30	60	90							2			90							30		34		34	14					363.95	25	25	25																							25																	25				25			25			
S5601	023	0		29	10	S5601_023_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	023	0		29	10	S5601_023_0	1	2	Preferred Brand	3	4	000101	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													49.57	30	30	30					57.83	35	35	35							30																	35				35			35	1		
S5601	023	0		29	10	S5601_023_0	1	1	Generic	3	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00		1		
S5601	023	0		29	10	S5601_023_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													64.98	35	35	35					83.54	45	45	45							35																	45				45			45			
S5601	023	0		29	10	S5601_023_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	023	0		29	10	S5601_023_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													485.79	33	33	33					485.79	33	33	33							33																	33				33			33			
S5601	024	0		29	10	S5601_024_0	1	1	Generic	1	2	010001		2	111100000010001000000101	30	60	90							1			90							30		34		34	14		2.00	4.00	5.00																								5.00																		2.00					2.00			2.00				
S5601	024	0		29	10	S5601_024_0	1	2	Preferred Brand	1	2	000101		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					26.19	24	24	24																							24																	24				24			24			
S5601	024	0		29	10	S5601_024_0	1	4	Specialty Tier	1	2	010010		1	111100000010001000000101	30	60	90							2			90							30		34		34	14					393.90	25	25	25																							25																	25				25			25			
S5601	024	0		29	10	S5601_024_0	1	3	Non-Preferred Brand	1	2	100100		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					94.76	49	49	49																							49																	49				49			49			
S5601	025	0		29	10	S5601_025_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													62.36	35	35	35					80.18	45	45	45							35																	45				45			45			
S5601	025	0		29	10	S5601_025_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	025	0		29	10	S5601_025_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	025	0		29	10	S5601_025_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													526.51	33	33	33					526.51	33	33	33							33																	33				33			33			
S5601	025	0		29	10	S5601_025_0	1	2	Preferred Brand	3	4	000101	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													51.34	30	30	30					59.90	35	35	35							30																	35				35			35	1		
S5601	025	0		29	10	S5601_025_0	1	1	Generic	3	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00		1		
S5601	026	0		29	10	S5601_026_0	1	1	Generic	1	2	010001		2	111100000010001000000101	30	60	90							1			90							30		34		34	14		2.00	4.00	5.00																								5.00																		2.00					2.00			2.00				
S5601	026	0		29	10	S5601_026_0	1	3	Non-Preferred Brand	1	2	100100		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					101.08	45	45	45																							45																	45				45			45			
S5601	026	0		29	10	S5601_026_0	1	4	Specialty Tier	1	2	010010		1	111100000010001000000101	30	60	90							2			90							30		34		34	14					408.56	25	25	25																							25																	25				25			25			
S5601	026	0		29	10	S5601_026_0	1	2	Preferred Brand	1	2	000101		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					27.88	24	24	24																							24																	24				24			24			
S5601	027	0		29	10	S5601_027_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													67.65	35	35	35					86.97	45	45	45							35																	45				45			45			
S5601	027	0		29	10	S5601_027_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	027	0		29	10	S5601_027_0	1	1	Generic	3	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00		1		
S5601	027	0		29	10	S5601_027_0	1	2	Preferred Brand	3	4	000101	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													56.50	30	30	30					65.91	35	35	35							30																	35				35			35	1		
S5601	027	0		29	10	S5601_027_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													499.59	33	33	33					499.59	33	33	33							33																	33				33			33			
S5601	027	0		29	10	S5601_027_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	028	0		29	10	S5601_028_0	1	2	Preferred Brand	1	2	000101		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					27.15	24	24	24																							24																	24				24			24			
S5601	028	0		29	10	S5601_028_0	1	1	Generic	1	2	010001		2	111100000010001000000101	30	60	90							1			90							30		34		34	14		2.00	4.00	5.00																								5.00																		2.00					2.00			2.00				
S5601	028	0		29	10	S5601_028_0	1	4	Specialty Tier	1	2	010010		1	111100000010001000000101	30	60	90							2			90							30		34		34	14					368.39	25	25	25																							25																	25				25			25			
S5601	028	0		29	10	S5601_028_0	1	3	Non-Preferred Brand	1	2	100100		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					94.41	44	44	44																							44																	44				44			44			
S5601	029	0		29	10	S5601_029_0	1	2	Preferred Brand	3	4	000101	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													54.73	30	30	30					63.86	35	35	35							30																	35				35			35	1		
S5601	029	0		29	10	S5601_029_0	1	1	Generic	3	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00		1		
S5601	029	0		29	10	S5601_029_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													483.97	33	33	33					483.97	33	33	33							33																	33				33			33			
S5601	029	0		29	10	S5601_029_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	029	0		29	10	S5601_029_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	029	0		29	10	S5601_029_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													65.88	35	35	35					84.70	45	45	45							35																	45				45			45			
S5601	030	0		29	10	S5601_030_0	1	4	Specialty Tier	1	2	010010		1	111100000010001000000101	30	60	90							2			90							30		34		34	14					377.25	25	25	25																							25																	25				25			25			
S5601	030	0		29	10	S5601_030_0	1	3	Non-Preferred Brand	1	2	100100		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					91.83	45	45	45																							45																	45				45			45			
S5601	030	0		29	10	S5601_030_0	1	2	Preferred Brand	1	2	000101		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					28.05	25	25	25																							25																	25				25			25			
S5601	030	0		29	10	S5601_030_0	1	1	Generic	1	2	010001		2	111100000010001000000101	30	60	90							1			90							30		34		34	14		2.00	4.00	5.00																								5.00																		2.00					2.00			2.00				
S5601	031	0		29	10	S5601_031_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	031	0		29	10	S5601_031_0	1	1	Generic	3	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00		1		
S5601	031	0		29	10	S5601_031_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													440.50	33	33	33					440.50	33	33	33							33																	33				33			33			
S5601	031	0		29	10	S5601_031_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													63.44	35	35	35					81.57	45	45	45							35																	45				45			45			
S5601	031	0		29	10	S5601_031_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	031	0		29	10	S5601_031_0	1	2	Preferred Brand	3	4	000101	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													50.42	30	30	30					58.83	35	35	35							30																	35				35			35	1		
S5601	032	0		29	10	S5601_032_0	1	1	Generic	1	2	010001		2	111100000010001000000101	30	60	90							1			90							30		34		34	14		2.00	4.00	5.00																								5.00																		2.00					2.00			2.00				
S5601	032	0		29	10	S5601_032_0	1	2	Preferred Brand	1	2	000101		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					24.62	23	23	23																							23																	23				23			23			
S5601	032	0		29	10	S5601_032_0	1	3	Non-Preferred Brand	1	2	100100		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					92.13	44	44	44																							44																	44				44			44			
S5601	032	0		29	10	S5601_032_0	1	4	Specialty Tier	1	2	010010		1	111100000010001000000101	30	60	90							2			90							30		34		34	14					362.36	25	25	25																							25																	25				25			25			
S5601	033	0		29	10	S5601_033_0	1	1	Generic	3	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00		1		
S5601	033	0		29	10	S5601_033_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	033	0		29	10	S5601_033_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													67.15	35	35	35					86.34	45	45	45							35																	45				45			45			
S5601	033	0		29	10	S5601_033_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													426.99	33	33	33					426.99	33	33	33							33																	33				33			33			
S5601	033	0		29	10	S5601_033_0	1	2	Preferred Brand	3	4	000101	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													52.84	30	30	30					61.64	35	35	35							30																	35				35			35	1		
S5601	033	0		29	10	S5601_033_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	034	0		29	10	S5601_034_0	1	4	Specialty Tier	1	2	010010		1	111100000010001000000101	30	60	90							2			90							30		34		34	14					373.10	25	25	25																							25																	25				25			25			
S5601	034	0		29	10	S5601_034_0	1	1	Generic	1	2	010001		2	111100000010001000000101	30	60	90							1			90							30		34		34	14		2.00	4.00	5.00																								5.00																		2.00					2.00			2.00				
S5601	034	0		29	10	S5601_034_0	1	2	Preferred Brand	1	2	000101		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					24.82	24	24	24																							24																	24				24			24			
S5601	034	0		29	10	S5601_034_0	1	3	Non-Preferred Brand	1	2	100100		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					89.49	44	44	44																							44																	44				44			44			
S5601	035	0		29	10	S5601_035_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	035	0		29	10	S5601_035_0	1	2	Preferred Brand	3	4	000101	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													48.66	30	30	30					56.76	35	35	35							30																	35				35			35	1		
S5601	035	0		29	10	S5601_035_0	1	1	Generic	3	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00		1		
S5601	035	0		29	10	S5601_035_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													441.30	33	33	33					441.30	33	33	33							33																	33				33			33			
S5601	035	0		29	10	S5601_035_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													63.84	35	35	35					82.09	45	45	45							35																	45				45			45			
S5601	035	0		29	10	S5601_035_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	036	0		29	10	S5601_036_0	1	4	Specialty Tier	1	2	010010		1	111100000010001000000101	30	60	90							2			90							30		34		34	14					370.70	25	25	25																							25																	25				25			25			
S5601	036	0		29	10	S5601_036_0	1	2	Preferred Brand	1	2	000101		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					26.85	24	24	24																							24																	24				24			24			
S5601	036	0		29	10	S5601_036_0	1	3	Non-Preferred Brand	1	2	100100		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					97.02	45	45	45																							45																	45				45			45			
S5601	036	0		29	10	S5601_036_0	1	1	Generic	1	2	010001		2	111100000010001000000101	30	60	90							1			90							30		34		34	14		2.00	4.00	5.00																								5.00																		2.00					2.00			2.00				
S5601	037	0		29	10	S5601_037_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	037	0		29	10	S5601_037_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	037	0		29	10	S5601_037_0	1	2	Preferred Brand	3	4	000101	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													49.09	30	30	30					57.27	35	35	35							30																	35				35			35	1		
S5601	037	0		29	10	S5601_037_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													64.56	35	35	35					83.01	45	45	45							35																	45				45			45			
S5601	037	0		29	10	S5601_037_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													562.00	33	33	33					562.00	33	33	33							33																	33				33			33			
S5601	037	0		29	10	S5601_037_0	1	1	Generic	3	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00		1		
S5601	038	0		29	10	S5601_038_0	1	4	Specialty Tier	1	2	010010		1	111100000010001000000101	30	60	90							2			90							30		34		34	14					400.66	25	25	25																							25																	25				25			25			
S5601	038	0		29	10	S5601_038_0	1	2	Preferred Brand	1	2	000101		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					25.70	25	25	25																							25																	25				25			25			
S5601	038	0		29	10	S5601_038_0	1	1	Generic	1	2	010001		2	111100000010001000000101	30	60	90							1			90							30		34		34	14		2.00	4.00	5.00																								5.00																		2.00					2.00			2.00				
S5601	038	0		29	10	S5601_038_0	1	3	Non-Preferred Brand	1	2	100100		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					99.94	50	50	50																							50																	50				50			50			
S5601	040	0		29	10	S5601_040_0	1	1	Generic	1	2	010001		2	111100000010001000000101	30	60	90							1			90							30		34		34	14		2.00	4.00	5.00																								5.00																		2.00					2.00			2.00				
S5601	040	0		29	10	S5601_040_0	1	4	Specialty Tier	1	2	010010		1	111100000010001000000101	30	60	90							2			90							30		34		34	14					410.55	25	25	25																							25																	25				25			25			
S5601	040	0		29	10	S5601_040_0	1	3	Non-Preferred Brand	1	2	100100		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					93.93	48	48	48																							48																	48				48			48			
S5601	040	0		29	10	S5601_040_0	1	2	Preferred Brand	1	2	000101		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					26.58	24	24	24																							24																	24				24			24			
S5601	041	0		29	10	S5601_041_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	041	0		29	10	S5601_041_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	041	0		29	10	S5601_041_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													490.61	33	33	33					490.61	33	33	33							33																	33				33			33			
S5601	041	0		29	10	S5601_041_0	1	1	Generic	3	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00		1		
S5601	041	0		29	10	S5601_041_0	1	2	Preferred Brand	3	4	000101	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													51.11	30	30	30					59.63	35	35	35							30																	35				35			35	1		
S5601	041	0		29	10	S5601_041_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													60.99	35	35	35					78.42	45	45	45							35																	45				45			45			
S5601	042	0		29	10	S5601_042_0	1	3	Non-Preferred Brand	1	2	100100		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					87.85	45	45	45																							45																	45				45			45			
S5601	042	0		29	10	S5601_042_0	1	4	Specialty Tier	1	2	010010		1	111100000010001000000101	30	60	90							2			90							30		34		34	14					385.48	25	25	25																							25																	25				25			25			
S5601	042	0		29	10	S5601_042_0	1	2	Preferred Brand	1	2	000101		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					23.88	23	23	23																							23																	23				23			23			
S5601	042	0		29	10	S5601_042_0	1	1	Generic	1	2	010001		2	111100000010001000000101	30	60	90							1			90							30		34		34	14		2.00	4.00	5.00																								5.00																		2.00					2.00			2.00				
S5601	044	0		29	10	S5601_044_0	1	4	Specialty Tier	1	2	010010		1	111100000010001000000101	30	60	90							2			90							30		34		34	14					392.03	25	25	25																							25																	25				25			25			
S5601	044	0		29	10	S5601_044_0	1	3	Non-Preferred Brand	1	2	100100		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					93.12	45	45	45																							45																	45				45			45			
S5601	044	0		29	10	S5601_044_0	1	2	Preferred Brand	1	2	000101		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					29.89	24	24	24																							24																	24				24			24			
S5601	044	0		29	10	S5601_044_0	1	1	Generic	1	2	010001		2	111100000010001000000101	30	60	90							1			90							30		34		34	14		2.00	4.00	5.00																								5.00																		2.00					2.00			2.00				
S5601	045	0		29	10	S5601_045_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	045	0		29	10	S5601_045_0	1	2	Preferred Brand	3	4	000101	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													51.69	30	30	30					60.31	35	35	35							30																	35				35			35	1		
S5601	045	0		29	10	S5601_045_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													65.65	35	35	35					84.40	45	45	45							35																	45				45			45			
S5601	045	0		29	10	S5601_045_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	045	0		29	10	S5601_045_0	1	1	Generic	3	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00		1		
S5601	045	0		29	10	S5601_045_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													526.49	33	33	33					526.49	33	33	33							33																	33				33			33			
S5601	046	0		29	10	S5601_046_0	1	4	Specialty Tier	1	2	010010		1	111100000010001000000101	30	60	90							2			90							30		34		34	14					400.06	25	25	25																							25																	25				25			25			
S5601	046	0		29	10	S5601_046_0	1	3	Non-Preferred Brand	1	2	100100		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					94.62	46	46	46																							46																	46				46			46			
S5601	046	0		29	10	S5601_046_0	1	1	Generic	1	2	010001		2	111100000010001000000101	30	60	90							1			90							30		34		34	14		2.00	4.00	5.00																								5.00																		2.00					2.00			2.00				
S5601	046	0		29	10	S5601_046_0	1	2	Preferred Brand	1	2	000101		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					28.59	25	25	25																							25																	25				25			25			
S5601	048	0		29	10	S5601_048_0	1	1	Generic	1	2	010001		2	111100000010001000000101	30	60	90							1			90							30		34		34	14		2.00	4.00	5.00																								5.00																		2.00					2.00			2.00				
S5601	048	0		29	10	S5601_048_0	1	4	Specialty Tier	1	2	010010		1	111100000010001000000101	30	60	90							2			90							30		34		34	14					374.78	25	25	25																							25																	25				25			25			
S5601	048	0		29	10	S5601_048_0	1	3	Non-Preferred Brand	1	2	100100		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					93.30	47	47	47																							47																	47				47			47			
S5601	048	0		29	10	S5601_048_0	1	2	Preferred Brand	1	2	000101		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					26.70	25	25	25																							25																	25				25			25			
S5601	049	0		29	10	S5601_049_0	1	1	Generic	3	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00		1		
S5601	049	0		29	10	S5601_049_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													468.76	33	33	33					468.76	33	33	33							33																	33				33			33			
S5601	049	0		29	10	S5601_049_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													65.51	35	35	35					84.23	45	45	45							35																	45				45			45			
S5601	049	0		29	10	S5601_049_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	049	0		29	10	S5601_049_0	1	2	Preferred Brand	3	4	000101	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													48.49	30	30	30					56.58	35	35	35							30																	35				35			35	1		
S5601	049	0		29	10	S5601_049_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	050	0		29	10	S5601_050_0	1	2	Preferred Brand	1	2	000101		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					25.87	25	25	25																							25																	25				25			25			
S5601	050	0		29	10	S5601_050_0	1	3	Non-Preferred Brand	1	2	100100		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					95.14	45	45	45																							45																	45				45			45			
S5601	050	0		29	10	S5601_050_0	1	1	Generic	1	2	010001		2	111100000010001000000101	30	60	90							1			90							30		34		34	14		2.00	4.00	5.00																								5.00																		2.00					2.00			2.00				
S5601	050	0		29	10	S5601_050_0	1	4	Specialty Tier	1	2	010010		1	111100000010001000000101	30	60	90							2			90							30		34		34	14					363.09	25	25	25																							25																	25				25			25			
S5601	051	0		29	10	S5601_051_0	1	1	Generic	3	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00		1		
S5601	051	0		29	10	S5601_051_0	1	2	Preferred Brand	3	4	000101	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													48.18	30	30	30					56.21	35	35	35							30																	35				35			35	1		
S5601	051	0		29	10	S5601_051_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													447.02	33	33	33					447.02	33	33	33							33																	33				33			33			
S5601	051	0		29	10	S5601_051_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	051	0		29	10	S5601_051_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	051	0		29	10	S5601_051_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													61.45	35	35	35					79.01	45	45	45							35																	45				45			45			
S5601	052	0		29	10	S5601_052_0	1	4	Specialty Tier	1	2	010010		1	111100000010001000000101	30	60	90							2			90							30		34		34	14					405.92	25	25	25																							25																	25				25			25			
S5601	052	0		29	10	S5601_052_0	1	3	Non-Preferred Brand	1	2	100100		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					89.90	46	46	46																							46																	46				46			46			
S5601	052	0		29	10	S5601_052_0	1	2	Preferred Brand	1	2	000101		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					27.45	25	25	25																							25																	25				25			25			
S5601	052	0		29	10	S5601_052_0	1	1	Generic	1	2	010001		2	111100000010001000000101	30	60	90							1			90							30		34		34	14		2.00	4.00	5.00																								5.00																		2.00					2.00			2.00				
S5601	053	0		29	10	S5601_053_0	1	1	Generic	3	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00		1		
S5601	053	0		29	10	S5601_053_0	1	2	Preferred Brand	3	4	000101	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													51.90	30	30	30					60.55	35	35	35							30																	35				35			35	1		
S5601	053	0		29	10	S5601_053_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													578.91	33	33	33					578.91	33	33	33							33																	33				33			33			
S5601	053	0		29	10	S5601_053_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													65.12	35	35	35					83.73	45	45	45							35																	45				45			45			
S5601	053	0		29	10	S5601_053_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	053	0		29	10	S5601_053_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	054	0		29	10	S5601_054_0	1	4	Specialty Tier	1	2	010010		1	111100000010001000000101	30	60	90							2			90							30		34		34	14					366.83	25	25	25																							25																	25				25			25			
S5601	054	0		29	10	S5601_054_0	1	3	Non-Preferred Brand	1	2	100100		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					95.93	45	45	45																							45																	45				45			45			
S5601	054	0		29	10	S5601_054_0	1	2	Preferred Brand	1	2	000101		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					26.50	23	23	23																							23																	23				23			23			
S5601	054	0		29	10	S5601_054_0	1	1	Generic	1	2	010001		2	111100000010001000000101	30	60	90							1			90							30		34		34	14		2.00	4.00	5.00																								5.00																		2.00					2.00			2.00				
S5601	055	0		29	10	S5601_055_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	055	0		29	10	S5601_055_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	055	0		29	10	S5601_055_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													65.00	35	35	35					83.58	45	45	45							35																	45				45			45			
S5601	055	0		29	10	S5601_055_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													433.49	33	33	33					433.49	33	33	33							33																	33				33			33			
S5601	055	0		29	10	S5601_055_0	1	2	Preferred Brand	3	4	000101	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													54.05	30	30	30					63.06	35	35	35							30																	35				35			35	1		
S5601	055	0		29	10	S5601_055_0	1	1	Generic	3	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00		1		
S5601	056	0		29	10	S5601_056_0	1	4	Specialty Tier	1	2	010010		1	111100000010001000000101	30	60	90							2			90							30		34		34	14					349.03	25	25	25																							25																	25				25			25			
S5601	056	0		29	10	S5601_056_0	1	3	Non-Preferred Brand	1	2	100100		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					78.23	44	44	44																							44																	44				44			44			
S5601	056	0		29	10	S5601_056_0	1	1	Generic	1	2	010001		2	111100000010001000000101	30	60	90							1			90							30		34		34	14		2.00	4.00	5.00																								5.00																		2.00					2.00			2.00				
S5601	056	0		29	10	S5601_056_0	1	2	Preferred Brand	1	2	000101		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					23.77	22	22	22																							22																	22				22			22			
S5601	057	0		29	10	S5601_057_0	1	1	Generic	3	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00		1		
S5601	057	0		29	10	S5601_057_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													459.68	33	33	33					459.68	33	33	33							33																	33				33			33			
S5601	057	0		29	10	S5601_057_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													64.76	35	35	35					83.27	45	45	45							35																	45				45			45			
S5601	057	0		29	10	S5601_057_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	057	0		29	10	S5601_057_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	057	0		29	10	S5601_057_0	1	2	Preferred Brand	3	4	000101	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													53.53	30	30	30					62.45	35	35	35							30																	35				35			35	1		
S5601	058	0		29	10	S5601_058_0	1	1	Generic	1	2	010001		2	111100000010001000000101	30	60	90							1			90							30		34		34	14		2.00	4.00	5.00																								5.00																		2.00					2.00			2.00				
S5601	058	0		29	10	S5601_058_0	1	2	Preferred Brand	1	2	000101		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					25.12	23	23	23																							23																	23				23			23			
S5601	058	0		29	10	S5601_058_0	1	4	Specialty Tier	1	2	010010		1	111100000010001000000101	30	60	90							2			90							30		34		34	14					337.50	25	25	25																							25																	25				25			25			
S5601	058	0		29	10	S5601_058_0	1	3	Non-Preferred Brand	1	2	100100		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					84.83	43	43	43																							43																	43				43			43			
S5601	059	0		29	10	S5601_059_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	059	0		29	10	S5601_059_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	059	0		29	10	S5601_059_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													68.25	35	35	35					87.75	45	45	45							35																	45				45			45			
S5601	059	0		29	10	S5601_059_0	1	1	Generic	3	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00		1		
S5601	059	0		29	10	S5601_059_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													439.09	33	33	33					439.09	33	33	33							33																	33				33			33			
S5601	059	0		29	10	S5601_059_0	1	2	Preferred Brand	3	4	000101	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													57.74	30	30	30					67.36	35	35	35							30																	35				35			35	1		
S5601	060	0		29	10	S5601_060_0	1	2	Preferred Brand	1	2	000101		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					25.88	25	25	25																							25																	25				25			25			
S5601	060	0		29	10	S5601_060_0	1	3	Non-Preferred Brand	1	2	100100		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					93.31	45	45	45																							45																	45				45			45			
S5601	060	0		29	10	S5601_060_0	1	4	Specialty Tier	1	2	010010		1	111100000010001000000101	30	60	90							2			90							30		34		34	14					378.13	25	25	25																							25																	25				25			25			
S5601	060	0		29	10	S5601_060_0	1	1	Generic	1	2	010001		2	111100000010001000000101	30	60	90							1			90							30		34		34	14		2.00	4.00	5.00																								5.00																		2.00					2.00			2.00				
S5601	061	0		29	10	S5601_061_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													446.18	33	33	33					446.18	33	33	33							33																	33				33			33			
S5601	061	0		29	10	S5601_061_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													65.71	35	35	35					84.48	45	45	45							35																	45				45			45			
S5601	061	0		29	10	S5601_061_0	1	2	Preferred Brand	3	4	000101	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													53.96	30	30	30					62.95	35	35	35							30																	35				35			35	1		
S5601	061	0		29	10	S5601_061_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	061	0		29	10	S5601_061_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	061	0		29	10	S5601_061_0	1	1	Generic	3	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00		1		
S5601	062	0		29	10	S5601_062_0	1	1	Generic	1	2	010001		2	111100000010001000000101	30	60	90							1			90							30		34		34	14		2.00	4.00	5.00																								5.00																		2.00					2.00			2.00				
S5601	062	0		29	10	S5601_062_0	1	4	Specialty Tier	1	2	010010		1	111100000010001000000101	30	60	90							2			90							30		34		34	14					377.49	25	25	25																							25																	25				25			25			
S5601	062	0		29	10	S5601_062_0	1	3	Non-Preferred Brand	1	2	100100		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					92.87	44	44	44																							44																	44				44			44			
S5601	062	0		29	10	S5601_062_0	1	2	Preferred Brand	1	2	000101		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					24.64	23	23	23																							23																	23				23			23			
S5601	063	0		29	10	S5601_063_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													598.13	33	33	33					598.13	33	33	33							33																	33				33			33			
S5601	063	0		29	10	S5601_063_0	1	1	Generic	3	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00		1		
S5601	063	0		29	10	S5601_063_0	1	2	Preferred Brand	3	4	000101	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													48.56	30	30	30					56.65	35	35	35							30																	35				35			35	1		
S5601	063	0		29	10	S5601_063_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	063	0		29	10	S5601_063_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													61.40	35	35	35					78.94	45	45	45							35																	45				45			45			
S5601	063	0		29	10	S5601_063_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	064	0		29	10	S5601_064_0	1	2	Preferred Brand	1	2	000101		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					24.57	21	21	21																							21																	21				21			21			
S5601	064	0		29	10	S5601_064_0	1	1	Generic	1	2	010001		2	111100000010001000000101	30	60	90							1			90							30		34		34	14		2.00	4.00	5.00																								5.00																		2.00					2.00			2.00				
S5601	064	0		29	10	S5601_064_0	1	4	Specialty Tier	1	2	010010		1	111100000010001000000101	30	60	90							2			90							30		34		34	14					392.32	25	25	25																							25																	25				25			25			
S5601	064	0		29	10	S5601_064_0	1	3	Non-Preferred Brand	1	2	100100		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					87.94	43	43	43																							43																	43				43			43			
S5601	065	0		29	10	S5601_065_0	1	2	Preferred Brand	3	4	000101	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													53.37	30	30	30					62.27	35	35	35							30																	35				35			35	1		
S5601	065	0		29	10	S5601_065_0	1	1	Generic	3	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00		1		
S5601	065	0		29	10	S5601_065_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													508.73	33	33	33					508.73	33	33	33							33																	33				33			33			
S5601	065	0		29	10	S5601_065_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													65.94	35	35	35					84.78	45	45	45							35																	45				45			45			
S5601	065	0		29	10	S5601_065_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	065	0		29	10	S5601_065_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	066	0		29	10	S5601_066_0	1	4	Specialty Tier	1	2	010010		1	111100000010001000000101	30	60	90							2			90							30		34		34	14					381.43	25	25	25																							25																	25				25			25			
S5601	066	0		29	10	S5601_066_0	1	1	Generic	1	2	010001		2	111100000010001000000101	30	60	90							1			90							30		34		34	14		2.00	4.00	5.00																								5.00																		2.00					2.00			2.00				
S5601	066	0		29	10	S5601_066_0	1	2	Preferred Brand	1	2	000101		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					26.38	23	23	23																							23																	23				23			23			
S5601	066	0		29	10	S5601_066_0	1	3	Non-Preferred Brand	1	2	100100		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					97.89	43	43	43																							43																	43				43			43			
S5601	067	0		29	10	S5601_067_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	067	0		29	10	S5601_067_0	1	2	Preferred Brand	3	4	000101	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													60.95	30	30	30					71.11	35	35	35							30																	35				35			35	1		
S5601	067	0		29	10	S5601_067_0	1	1	Generic	3	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00		1		
S5601	067	0		29	10	S5601_067_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													464.62	33	33	33					464.62	33	33	33							33																	33				33			33			
S5601	067	0		29	10	S5601_067_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	067	0		29	10	S5601_067_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													66.49	35	35	35					85.49	45	45	45							35																	45				45			45			
S5601	068	0		29	10	S5601_068_0	1	1	Generic	1	2	010001		2	111100000010001000000101	30	60	90							1			90							30		34		34	14		2.00	4.00	5.00																								5.00																		2.00					2.00			2.00				
S5601	068	0		29	10	S5601_068_0	1	4	Specialty Tier	1	2	010010		1	111100000010001000000101	30	60	90							2			90							30		34		34	14					326.95	25	25	25																							25																	25				25			25			
S5601	068	0		29	10	S5601_068_0	1	2	Preferred Brand	1	2	000101		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					17.27	21	21	21																							21																	21				21			21			
S5601	068	0		29	10	S5601_068_0	1	3	Non-Preferred Brand	1	2	100100		1	111100000010001000000101	30	60	90							1			90							30		34		34	14					65.06	41	41	41																							41																	41				41			41			
S5601	107	0		29	10	S5601_107_0	1	2	Preferred Brand	3	4	000101	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													47.73	30	30	30					55.69	35	35	35							30																	35				35			35	1		
S5601	107	0		29	10	S5601_107_0	1	1	Generic	3	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00		1		
S5601	107	0		29	10	S5601_107_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													559.27	33	33	33					559.27	33	33	33							33																	33				33			33			
S5601	107	0		29	10	S5601_107_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													63.68	35	35	35					81.87	45	45	45							35																	45				45			45			
S5601	107	0		29	10	S5601_107_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	107	0		29	10	S5601_107_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	108	0		29	10	S5601_108_0	1	1	Generic	3	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00		1		
S5601	108	0		29	10	S5601_108_0	1	2	Preferred Brand	3	4	000101	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													47.88	30	30	30					55.86	35	35	35							30																	35				35			35	1		
S5601	108	0		29	10	S5601_108_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													501.70	33	33	33					501.70	33	33	33							33																	33				33			33			
S5601	108	0		29	10	S5601_108_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													63.44	35	35	35					81.56	45	45	45							35																	45				45			45			
S5601	108	0		29	10	S5601_108_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	108	0		29	10	S5601_108_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	109	0		29	10	S5601_109_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	109	0		29	10	S5601_109_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	109	0		29	10	S5601_109_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													67.53	35	35	35					86.83	45	45	45							35																	45				45			45			
S5601	109	0		29	10	S5601_109_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													462.17	33	33	33					462.17	33	33	33							33																	33				33			33			
S5601	109	0		29	10	S5601_109_0	1	1	Generic	3	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00		1		
S5601	109	0		29	10	S5601_109_0	1	2	Preferred Brand	3	4	000101	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													49.41	30	30	30					57.65	35	35	35							30																	35				35			35	1		
S5601	110	0		29	10	S5601_110_0	2	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	110	0		29	10	S5601_110_0	2	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													483.65	33	33	33					483.65	33	33	33							33																	33				33			33			
S5601	110	0		29	10	S5601_110_0	2	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													68.41	35	35	35					87.95	45	45	45							35																	45				45			45			
S5601	110	0		29	10	S5601_110_0	2	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	111	0		29	10	S5601_111_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													68.41	35	35	35					87.95	45	45	45							35																	45				45			45			
S5601	111	0		29	10	S5601_111_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	111	0		29	10	S5601_111_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	111	0		29	10	S5601_111_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													483.65	33	33	33					483.65	33	33	33							33																	33				33			33			
S5601	112	0		29	10	S5601_112_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													483.65	33	33	33					483.65	33	33	33							33																	33				33			33			
S5601	112	0		29	10	S5601_112_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													68.41	35	35	35					87.95	45	45	45							35																	45				45			45			
S5601	112	0		29	10	S5601_112_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	112	0		29	10	S5601_112_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	113	0		29	10	S5601_113_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													487.28	33	33	33					487.28	33	33	33							33																	33				33			33			
S5601	113	0		29	10	S5601_113_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	113	0		29	10	S5601_113_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	113	0		29	10	S5601_113_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													68.30	35	35	35					87.82	45	45	45							35																	45				45			45			
S5601	114	0		29	10	S5601_114_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													68.53	35	35	35					88.11	45	45	45							35																	45				45			45			
S5601	114	0		29	10	S5601_114_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	114	0		29	10	S5601_114_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	114	0		29	10	S5601_114_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													481.04	33	33	33					481.04	33	33	33							33																	33				33			33			
S5601	115	0		29	10	S5601_115_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	115	0		29	10	S5601_115_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	115	0		29	10	S5601_115_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													68.41	35	35	35					87.95	45	45	45							35																	45				45			45			
S5601	115	0		29	10	S5601_115_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													483.65	33	33	33					483.65	33	33	33							33																	33				33			33			
S5601	116	0		29	10	S5601_116_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													483.65	33	33	33					483.65	33	33	33							33																	33				33			33			
S5601	116	0		29	10	S5601_116_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	116	0		29	10	S5601_116_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	116	0		29	10	S5601_116_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													68.41	35	35	35					87.95	45	45	45							35																	45				45			45			
S5601	117	0		29	10	S5601_117_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	117	0		29	10	S5601_117_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	117	0		29	10	S5601_117_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													483.65	33	33	33					483.65	33	33	33							33																	33				33			33			
S5601	117	0		29	10	S5601_117_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													68.41	35	35	35					87.95	45	45	45							35																	45				45			45			
S5601	118	0		29	10	S5601_118_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													483.65	33	33	33					483.65	33	33	33							33																	33				33			33			
S5601	118	0		29	10	S5601_118_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													68.41	35	35	35					87.95	45	45	45							35																	45				45			45			
S5601	118	0		29	10	S5601_118_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	118	0		29	10	S5601_118_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	119	0		29	10	S5601_119_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													68.41	35	35	35					87.95	45	45	45							35																	45				45			45			
S5601	119	0		29	10	S5601_119_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	119	0		29	10	S5601_119_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	119	0		29	10	S5601_119_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													483.65	33	33	33					483.65	33	33	33							33																	33				33			33			
S5601	120	0		29	10	S5601_120_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													68.33	35	35	35					87.85	45	45	45							35																	45				45			45			
S5601	120	0		29	10	S5601_120_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	120	0		29	10	S5601_120_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													485.94	33	33	33					485.94	33	33	33							33																	33				33			33			
S5601	120	0		29	10	S5601_120_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	121	0		29	10	S5601_121_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													68.41	35	35	35					87.95	45	45	45							35																	45				45			45			
S5601	121	0		29	10	S5601_121_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	121	0		29	10	S5601_121_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													483.65	33	33	33					483.65	33	33	33							33																	33				33			33			
S5601	121	0		29	10	S5601_121_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	122	0		29	10	S5601_122_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													68.41	35	35	35					87.95	45	45	45							35																	45				45			45			
S5601	122	0		29	10	S5601_122_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	122	0		29	10	S5601_122_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													483.65	33	33	33					483.65	33	33	33							33																	33				33			33			
S5601	122	0		29	10	S5601_122_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	123	0		29	10	S5601_123_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													68.41	35	35	35					87.95	45	45	45							35																	45				45			45			
S5601	123	0		29	10	S5601_123_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	123	0		29	10	S5601_123_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													483.65	33	33	33					483.65	33	33	33							33																	33				33			33			
S5601	123	0		29	10	S5601_123_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	124	0		29	10	S5601_124_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													68.41	35	35	35					87.95	45	45	45							35																	45				45			45			
S5601	124	0		29	10	S5601_124_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	124	0		29	10	S5601_124_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													483.65	33	33	33					483.65	33	33	33							33																	33				33			33			
S5601	124	0		29	10	S5601_124_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	125	0		29	10	S5601_125_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													68.41	35	35	35					87.95	45	45	45							35																	45				45			45			
S5601	125	0		29	10	S5601_125_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	125	0		29	10	S5601_125_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													483.65	33	33	33					483.65	33	33	33							33																	33				33			33			
S5601	125	0		29	10	S5601_125_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	126	0		29	10	S5601_126_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	126	0		29	10	S5601_126_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													483.65	33	33	33					483.65	33	33	33							33																	33				33			33			
S5601	126	0		29	10	S5601_126_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													68.41	35	35	35					87.95	45	45	45							35																	45				45			45			
S5601	126	0		29	10	S5601_126_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	127	0		29	10	S5601_127_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	127	0		29	10	S5601_127_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	127	0		29	10	S5601_127_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													68.41	35	35	35					87.95	45	45	45							35																	45				45			45			
S5601	127	0		29	10	S5601_127_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													483.65	33	33	33					483.65	33	33	33							33																	33				33			33			
S5601	128	0		29	10	S5601_128_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	128	0		29	10	S5601_128_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	128	0		29	10	S5601_128_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													68.41	35	35	35					87.95	45	45	45							35																	45				45			45			
S5601	128	0		29	10	S5601_128_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													483.65	33	33	33					483.65	33	33	33							33																	33				33			33			
S5601	129	0		29	10	S5601_129_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	129	0		29	10	S5601_129_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	129	0		29	10	S5601_129_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													68.41	35	35	35					87.95	45	45	45							35																	45				45			45			
S5601	129	0		29	10	S5601_129_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													483.65	33	33	33					483.65	33	33	33							33																	33				33			33			
S5601	130	0		29	10	S5601_130_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													68.41	35	35	35					87.95	45	45	45							35																	45				45			45			
S5601	130	0		29	10	S5601_130_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													483.65	33	33	33					483.65	33	33	33							33																	33				33			33			
S5601	130	0		29	10	S5601_130_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	130	0		29	10	S5601_130_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	131	0		29	10	S5601_131_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	131	0		29	10	S5601_131_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	131	0		29	10	S5601_131_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													68.41	35	35	35					87.95	45	45	45							35																	45				45			45			
S5601	131	0		29	10	S5601_131_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													483.65	33	33	33					483.65	33	33	33							33																	33				33			33			
S5601	132	0		29	10	S5601_132_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													483.65	33	33	33					483.65	33	33	33							33																	33				33			33			
S5601	132	0		29	10	S5601_132_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	132	0		29	10	S5601_132_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	132	0		29	10	S5601_132_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													68.41	35	35	35					87.95	45	45	45							35																	45				45			45			
S5601	133	0		29	10	S5601_133_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													483.65	33	33	33					483.65	33	33	33							33																	33				33			33			
S5601	133	0		29	10	S5601_133_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	133	0		29	10	S5601_133_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	133	0		29	10	S5601_133_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													68.41	35	35	35					87.95	45	45	45							35																	45				45			45			
S5601	134	0		29	10	S5601_134_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													68.41	35	35	35					87.95	45	45	45							35																	45				45			45			
S5601	134	0		29	10	S5601_134_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	134	0		29	10	S5601_134_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	134	0		29	10	S5601_134_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													483.65	33	33	33					483.65	33	33	33							33																	33				33			33			
S5601	135	0		29	10	S5601_135_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													68.41	35	35	35					87.95	45	45	45							35																	45				45			45			
S5601	135	0		29	10	S5601_135_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													483.65	33	33	33					483.65	33	33	33							33																	33				33			33			
S5601	135	0		29	10	S5601_135_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	135	0		29	10	S5601_135_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	136	0		29	10	S5601_136_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	136	0		29	10	S5601_136_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	136	0		29	10	S5601_136_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													68.41	35	35	35					87.95	45	45	45							35																	45				45			45			
S5601	136	0		29	10	S5601_136_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													483.65	33	33	33					483.65	33	33	33							33																	33				33			33			
S5601	137	0		29	10	S5601_137_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													68.41	35	35	35					87.95	45	45	45							35																	45				45			45			
S5601	137	0		29	10	S5601_137_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													483.65	33	33	33					483.65	33	33	33							33																	33				33			33			
S5601	137	0		29	10	S5601_137_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	137	0		29	10	S5601_137_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	138	0		29	10	S5601_138_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	138	0		29	10	S5601_138_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	138	0		29	10	S5601_138_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													68.41	35	35	35					87.95	45	45	45							35																	45				45			45			
S5601	138	0		29	10	S5601_138_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													483.65	33	33	33					483.65	33	33	33							33																	33				33			33			
S5601	139	0		29	10	S5601_139_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													480.41	33	33	33					480.41	33	33	33							33																	33				33			33			
S5601	139	0		29	10	S5601_139_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													68.56	35	35	35					88.15	45	45	45							35																	45				45			45			
S5601	139	0		29	10	S5601_139_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	139	0		29	10	S5601_139_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	140	0		29	10	S5601_140_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													483.65	33	33	33					483.65	33	33	33							33																	33				33			33			
S5601	140	0		29	10	S5601_140_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													68.41	35	35	35					87.95	45	45	45							35																	45				45			45			
S5601	140	0		29	10	S5601_140_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	140	0		29	10	S5601_140_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	141	0		29	10	S5601_141_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													486.30	33	33	33					486.30	33	33	33							33																	33				33			33			
S5601	141	0		29	10	S5601_141_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													68.32	35	35	35					87.84	45	45	45							35																	45				45			45			
S5601	141	0		29	10	S5601_141_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	141	0		29	10	S5601_141_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	142	0		29	10	S5601_142_0	1	1	Generic	1	4	010001	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										0.00	0.00	0.00						7.00	14.00	21.00								0.00																		7.00					7.00			7.00				
S5601	142	0		29	10	S5601_142_0	1	4	Specialty Tier	1	4	010010	1	1	100011111110001000000101				30	60	90	30	60	90	2			90							30		34		34	14													483.65	33	33	33					483.65	33	33	33							33																	33				33			33			
S5601	142	0		29	10	S5601_142_0	1	2	Preferred Brand	1	4	000101	1	2	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14										34.00	68.00	85.00						41.00	82.00	123.00								85.00																		41.00					41.00			41.00				
S5601	142	0		29	10	S5601_142_0	1	3	Non-Preferred Brand	1	4	100100	1	1	100011111110001000000101				30	60	90	30	60	90	1			90							30		34		34	14													68.41	35	35	35					87.95	45	45	45							35																	45				45			45			
S5609	001	0		29	10	S5609_001_0	5	6	Injectable Drugs	1	3	101101		1	110000000010100000000101	30										30									30		31		31	14					53.00	28																							28																			28				28			28			
S5609	001	0		29	10	S5609_001_0	5	5	Specialty Tier	1	3	101101		1	110000000010100000000101	30										30									30		31		31	14					420.00	28																							28																			28				28			28			
S5609	001	0		29	10	S5609_001_0	5	3	Preferred Brand	1	3	000001		2	110100000010101000000001	30		90							1	30		90							30				31	14	1.33	40.00		120.00																					1.33	40.00		100.00																		40.00							1.29	40.00				
S5609	001	0		29	10	S5609_001_0	5	2	Non-Preferred Generic	1	3	000100		2	010100000010101000000100	30		90							1	30		90							30		31				1.10	33.00		99.00																					1.10	33.00		66.00																		33.00				1.06	33.00							
S5609	001	0		29	10	S5609_001_0	5	1	Preferred Generic	1	3	001000		2	010100000010101000000100	30		90							1	30		90							30		31				0.25	7.50		22.50																					0.25	7.50		15.00																		7.50				0.24	7.50							
S5609	001	0		29	10	S5609_001_0	5	4	Non-Preferred Brand	1	3	100000		2	110100000010101000000001	30		90							1	30		90							30				31	14	2.83	85.00		255.00																					2.83	85.00		212.50																		85.00							2.74	85.00				
S5609	002	0		29	10	S5609_002_0	5	6	Injectable Drugs	1	4	101101	1	1	110000000010100000000101	30										30									30		31		31	14					65.00	33																							33																			33				33			33			
S5609	002	0		29	10	S5609_002_0	5	5	Specialty Tier	1	4	101101	1	1	110000000010100000000101	30										30									30		31		31	14					439.00	33																							33																			33				33			33			
S5609	002	0		29	10	S5609_002_0	5	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							1	30		90							30				31	14	2.83	85.00		255.00																					2.83	85.00		212.50																		85.00							2.74	85.00				
S5609	002	0		29	10	S5609_002_0	5	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							1	30		90							30				31	14	1.33	40.00		120.00																					1.33	40.00		100.00																		40.00							1.29	40.00				
S5609	002	0		29	10	S5609_002_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							1	30		90							30		31				1.10	33.00		99.00																					1.10	33.00		66.00																		33.00				1.06	33.00							
S5609	002	0		29	10	S5609_002_0	5	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							1	30		90							30		31				0.16	5.00		15.00																					0.16	5.00		10.00																		5.00				0.16	5.00							
S5609	002	0		29	10	S5609_002_0	5	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		90							1	30		90							30		31				0.16	5.00		15.00																					0.16	5.00		10.00																		5.00				0.16	5.00					1		
S5617	003	0		29	10	S5617_003_0	5	5	Specialty Tier	1	3	010010		1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					340.46	25	25	25																												25		25					25		25				25			25			25			
S5617	003	0		29	10	S5617_003_0	5	4	Non-Preferred Brand	1	3	100100		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		87.00	174.00	261.00																													87.00		217.50					87.00		261.00					87.00			2.80	87.00		2.80	87.00				
S5617	003	0		29	10	S5617_003_0	5	3	Preferred Brand	1	3	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		25.00	50.00	75.00																													25.00		62.50					25.00		75.00					25.00			.80	25.00		.80	25.00				
S5617	003	0		29	10	S5617_003_0	5	2	Non-Preferred Generic	1	3	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		8.00	16.00	24.00																													8.00		20.00					8.00		24.00					8.00			.25	8.00		.25	8.00				
S5617	003	0		29	10	S5617_003_0	5	1	Preferred Generic	1	3	001001		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	008	0		29	10	S5617_008_0	3	5	Specialty Tier	1	2	010010		1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					421.49	25	25	25																												25		25					25		25				25			25			25			
S5617	008	0		29	10	S5617_008_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		85.00	170.00	255.00																													85.00		212.50					85.00		255.00					85.00			2.74	85.00		2.74	85.00				
S5617	008	0		29	10	S5617_008_0	3	3	Preferred Brand	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		35.00	70.00	105.00																													35.00		87.50					35.00		105.00					35.00			1.12	35.00		1.12	35.00				
S5617	008	0		29	10	S5617_008_0	3	2	Non-Preferred Generic	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		8.00	16.00	24.00																													8.00		20.00					8.00		24.00					8.00			.25	8.00		.25	8.00				
S5617	008	0		29	10	S5617_008_0	3	1	Preferred Generic	1	2	001001		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	013	0		29	10	S5617_013_0	3	5	Specialty Tier	1	2	010010		1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					407.92	25	25	25																												25		25					25		25				25			25			25			
S5617	013	0		29	10	S5617_013_0	3	1	Preferred Generic	1	2	001001		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	013	0		29	10	S5617_013_0	3	2	Non-Preferred Generic	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		8.00	16.00	24.00																													8.00		20.00					8.00		24.00					8.00			.25	8.00		.25	8.00				
S5617	013	0		29	10	S5617_013_0	3	3	Preferred Brand	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		35.00	70.00	105.00																													35.00		87.50					35.00		105.00					35.00			1.12	35.00		1.12	35.00				
S5617	013	0		29	10	S5617_013_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		89.00	178.00	267.00																													89.00		222.50					89.00		267.00					89.00			2.87	89.00		2.87	89.00				
S5617	018	0		29	10	S5617_018_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		85.00	170.00	255.00																													85.00		212.50					85.00		255.00					85.00			2.74	85.00		2.74	85.00				
S5617	018	0		29	10	S5617_018_0	3	5	Specialty Tier	1	2	010010		1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					464.20	25	25	25																												25		25					25		25				25			25			25			
S5617	018	0		29	10	S5617_018_0	3	3	Preferred Brand	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		37.00	74.00	111.00																													37.00		92.50					37.00		111.00					37.00			1.19	37.00		1.19	37.00				
S5617	018	0		29	10	S5617_018_0	3	2	Non-Preferred Generic	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		8.00	16.00	24.00																													8.00		20.00					8.00		24.00					8.00			.25	8.00		.25	8.00				
S5617	018	0		29	10	S5617_018_0	3	1	Preferred Generic	1	2	001001		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	053	0		29	10	S5617_053_0	3	2	Non-Preferred Generic	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		8.00	16.00	24.00																													8.00		20.00					8.00		24.00					8.00			.25	8.00		.25	8.00				
S5617	053	0		29	10	S5617_053_0	3	1	Preferred Generic	1	2	001001		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	053	0		29	10	S5617_053_0	3	3	Preferred Brand	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		28.00	56.00	84.00																													28.00		70.00					28.00		84.00					28.00			.90	28.00		.90	28.00				
S5617	053	0		29	10	S5617_053_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		72.00	144.00	216.00																													72.00		180.00					72.00		216.00					72.00			2.32	72.00		2.32	72.00				
S5617	053	0		29	10	S5617_053_0	3	5	Specialty Tier	1	2	010010		1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					419.30	25	25	25																												25		25					25		25				25			25			25			
S5617	068	0		29	10	S5617_068_0	3	2	Non-Preferred Generic	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		8.00	16.00	24.00																													8.00		20.00					8.00		24.00					8.00			.25	8.00		.25	8.00				
S5617	068	0		29	10	S5617_068_0	3	1	Preferred Generic	1	2	001001		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	068	0		29	10	S5617_068_0	3	3	Preferred Brand	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		33.00	66.00	99.00																													33.00		82.50					33.00		99.00					33.00			1.06	33.00		1.06	33.00				
S5617	068	0		29	10	S5617_068_0	3	5	Specialty Tier	1	2	010010		1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					439.53	25	25	25																												25		25					25		25				25			25			25			
S5617	068	0		29	10	S5617_068_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		79.00	158.00	237.00																													79.00		197.50					79.00		237.00					79.00			2.54	79.00		2.54	79.00				
S5617	088	0		29	10	S5617_088_0	3	5	Specialty Tier	1	2	010010		1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					393.01	25	25	25																												25		25					25		25				25			25			25			
S5617	088	0		29	10	S5617_088_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		82.00	164.00	246.00																													82.00		205.00					82.00		246.00					82.00			2.64	82.00		2.64	82.00				
S5617	088	0		29	10	S5617_088_0	3	2	Non-Preferred Generic	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		8.00	16.00	24.00																													8.00		20.00					8.00		24.00					8.00			.25	8.00		.25	8.00				
S5617	088	0		29	10	S5617_088_0	3	3	Preferred Brand	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		30.00	60.00	90.00																													30.00		75.00					30.00		90.00					30.00			.96	30.00		.96	30.00				
S5617	088	0		29	10	S5617_088_0	3	1	Preferred Generic	1	2	001001		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	103	0		29	10	S5617_103_0	3	2	Non-Preferred Generic	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		8.00	16.00	24.00																													8.00		20.00					8.00		24.00					8.00			.25	8.00		.25	8.00				
S5617	103	0		29	10	S5617_103_0	3	1	Preferred Generic	1	2	001001		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	103	0		29	10	S5617_103_0	3	3	Preferred Brand	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		28.00	56.00	84.00																													28.00		70.00					28.00		84.00					28.00			.90	28.00		.90	28.00				
S5617	103	0		29	10	S5617_103_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		75.00	150.00	225.00																													75.00		187.50					75.00		225.00					75.00			2.41	75.00		2.41	75.00				
S5617	103	0		29	10	S5617_103_0	3	5	Specialty Tier	1	2	010010		1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					390.34	25	25	25																												25		25					25		25				25			25			25			
S5617	108	0		29	10	S5617_108_0	3	2	Non-Preferred Generic	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		8.00	16.00	24.00																													8.00		20.00					8.00		24.00					8.00			.25	8.00		.25	8.00				
S5617	108	0		29	10	S5617_108_0	3	1	Preferred Generic	1	2	001001		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	108	0		29	10	S5617_108_0	3	3	Preferred Brand	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		31.00	62.00	93.00																													31.00		77.50					31.00		93.00					31.00			1.00	31.00		1.00	31.00				
S5617	108	0		29	10	S5617_108_0	3	5	Specialty Tier	1	2	010010		1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					412.67	25	25	25																												25		25					25		25				25			25			25			
S5617	108	0		29	10	S5617_108_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		77.00	154.00	231.00																													77.00		192.50					77.00		231.00					77.00			2.48	77.00		2.48	77.00				
S5617	113	0		29	10	S5617_113_0	3	1	Preferred Generic	1	2	001001		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	113	0		29	10	S5617_113_0	3	2	Non-Preferred Generic	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		8.00	16.00	24.00																													8.00		20.00					8.00		24.00					8.00			.25	8.00		.25	8.00				
S5617	113	0		29	10	S5617_113_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		75.00	150.00	225.00																													75.00		187.50					75.00		225.00					75.00			2.41	75.00		2.41	75.00				
S5617	113	0		29	10	S5617_113_0	3	3	Preferred Brand	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		25.00	50.00	75.00																													25.00		62.50					25.00		75.00					25.00			.80	25.00		.80	25.00				
S5617	113	0		29	10	S5617_113_0	3	5	Specialty Tier	1	2	010010		1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					423.00	25	25	25																												25		25					25		25				25			25			25			
S5617	118	0		29	10	S5617_118_0	3	5	Specialty Tier	1	2	010010		1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					421.34	25	25	25																												25		25					25		25				25			25			25			
S5617	118	0		29	10	S5617_118_0	3	1	Preferred Generic	1	2	001001		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	118	0		29	10	S5617_118_0	3	2	Non-Preferred Generic	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		8.00	16.00	24.00																													8.00		20.00					8.00		24.00					8.00			.25	8.00		.25	8.00				
S5617	118	0		29	10	S5617_118_0	3	3	Preferred Brand	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		28.00	56.00	84.00																													28.00		70.00					28.00		84.00					28.00			.90	28.00		.90	28.00				
S5617	118	0		29	10	S5617_118_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		70.00	140.00	210.00																													70.00		175.00					70.00		210.00					70.00			2.25	70.00		2.25	70.00				
S5617	123	0		29	10	S5617_123_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		84.00	168.00	252.00																													84.00		210.00					84.00		252.00					84.00			2.70	84.00		2.70	84.00				
S5617	123	0		29	10	S5617_123_0	3	3	Preferred Brand	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		35.00	70.00	105.00																													35.00		87.50					35.00		105.00					35.00			1.12	35.00		1.12	35.00				
S5617	123	0		29	10	S5617_123_0	3	2	Non-Preferred Generic	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		8.00	16.00	24.00																													8.00		20.00					8.00		24.00					8.00			.25	8.00		.25	8.00				
S5617	123	0		29	10	S5617_123_0	3	1	Preferred Generic	1	2	001001		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	123	0		29	10	S5617_123_0	3	5	Specialty Tier	1	2	010010		1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					410.24	25	25	25																												25		25					25		25				25			25			25			
S5617	128	0		29	10	S5617_128_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		73.00	146.00	219.00																													73.00		182.50					73.00		219.00					73.00			2.35	73.00		2.35	73.00				
S5617	128	0		29	10	S5617_128_0	3	3	Preferred Brand	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		30.00	60.00	90.00																													30.00		75.00					30.00		90.00					30.00			.96	30.00		.96	30.00				
S5617	128	0		29	10	S5617_128_0	3	2	Non-Preferred Generic	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		8.00	16.00	24.00																													8.00		20.00					8.00		24.00					8.00			.25	8.00		.25	8.00				
S5617	128	0		29	10	S5617_128_0	3	1	Preferred Generic	1	2	001001		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	128	0		29	10	S5617_128_0	3	5	Specialty Tier	1	2	010010		1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					380.79	25	25	25																												25		25					25		25				25			25			25			
S5617	133	0		29	10	S5617_133_0	3	1	Preferred Generic	1	2	001001		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	133	0		29	10	S5617_133_0	3	2	Non-Preferred Generic	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		8.00	16.00	24.00																													8.00		20.00					8.00		24.00					8.00			.25	8.00		.25	8.00				
S5617	133	0		29	10	S5617_133_0	3	3	Preferred Brand	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		29.00	58.00	87.00																													29.00		72.50					29.00		87.00					29.00			.93	29.00		.93	29.00				
S5617	133	0		29	10	S5617_133_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		70.00	140.00	210.00																													70.00		175.00					70.00		210.00					70.00			2.25	70.00		2.25	70.00				
S5617	133	0		29	10	S5617_133_0	3	5	Specialty Tier	1	2	010010		1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					413.59	25	25	25																												25		25					25		25				25			25			25			
S5617	138	0		29	10	S5617_138_0	3	1	Preferred Generic	1	2	001001		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	138	0		29	10	S5617_138_0	3	2	Non-Preferred Generic	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		8.00	16.00	24.00																													8.00		20.00					8.00		24.00					8.00			.25	8.00		.25	8.00				
S5617	138	0		29	10	S5617_138_0	3	3	Preferred Brand	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		30.00	60.00	90.00																													30.00		75.00					30.00		90.00					30.00			.96	30.00		.96	30.00				
S5617	138	0		29	10	S5617_138_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		72.00	144.00	216.00																													72.00		180.00					72.00		216.00					72.00			2.32	72.00		2.32	72.00				
S5617	138	0		29	10	S5617_138_0	3	5	Specialty Tier	1	2	010010		1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					457.80	25	25	25																												25		25					25		25				25			25			25			
S5617	143	0		29	10	S5617_143_0	3	1	Preferred Generic	1	2	001001		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	143	0		29	10	S5617_143_0	3	2	Non-Preferred Generic	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		8.00	16.00	24.00																													8.00		20.00					8.00		24.00					8.00			.25	8.00		.25	8.00				
S5617	143	0		29	10	S5617_143_0	3	3	Preferred Brand	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		32.00	64.00	96.00																													32.00		80.00					32.00		96.00					32.00			1.03	32.00		1.03	32.00				
S5617	143	0		29	10	S5617_143_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		76.00	152.00	228.00																													76.00		190.00					76.00		228.00					76.00			2.45	76.00		2.45	76.00				
S5617	143	0		29	10	S5617_143_0	3	5	Specialty Tier	1	2	010010		1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					398.08	25	25	25																												25		25					25		25				25			25			25			
S5617	148	0		29	10	S5617_148_0	4	1	Preferred Generic	1	2	001001		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	148	0		29	10	S5617_148_0	4	2	Non-Preferred Generic	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		8.00	16.00	24.00																													8.00		20.00					8.00		24.00					8.00			.25	8.00		.25	8.00				
S5617	148	0		29	10	S5617_148_0	4	3	Preferred Brand	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		26.00	52.00	78.00																													26.00		65.00					26.00		78.00					26.00			.83	26.00		.83	26.00				
S5617	148	0		29	10	S5617_148_0	4	4	Non-Preferred Brand	1	2	100100		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		72.00	144.00	216.00																													72.00		180.00					72.00		216.00					72.00			2.32	72.00		2.32	72.00				
S5617	148	0		29	10	S5617_148_0	4	5	Specialty Tier	1	2	010010		1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					525.16	25	25	25																												25		25					25		25				25			25			25			
S5617	153	0		29	10	S5617_153_0	5	4	Non-Preferred Brand	1	3	100100		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		80.00	160.00	240.00																													80.00		200.00					80.00		240.00					80.00			2.58	80.00		2.58	80.00				
S5617	153	0		29	10	S5617_153_0	5	3	Preferred Brand	1	3	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		26.00	52.00	78.00																													26.00		65.00					26.00		78.00					26.00			.83	26.00		.83	26.00				
S5617	153	0		29	10	S5617_153_0	5	2	Non-Preferred Generic	1	3	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		8.00	16.00	24.00																													8.00		20.00					8.00		24.00					8.00			.25	8.00		.25	8.00				
S5617	153	0		29	10	S5617_153_0	5	1	Preferred Generic	1	3	001001		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	153	0		29	10	S5617_153_0	5	5	Specialty Tier	1	3	010010		1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					409.60	25	25	25																												25		25					25		25				25			25			25			
S5617	158	0		29	10	S5617_158_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		70.00	140.00	210.00																													70.00		175.00					70.00		210.00					70.00			2.25	70.00		2.25	70.00				
S5617	158	0		29	10	S5617_158_0	3	3	Preferred Brand	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		28.00	56.00	84.00																													28.00		70.00					28.00		84.00					28.00			.90	28.00		.90	28.00				
S5617	158	0		29	10	S5617_158_0	3	2	Non-Preferred Generic	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		8.00	16.00	24.00																													8.00		20.00					8.00		24.00					8.00			.25	8.00		.25	8.00				
S5617	158	0		29	10	S5617_158_0	3	1	Preferred Generic	1	2	001001		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	158	0		29	10	S5617_158_0	3	5	Specialty Tier	1	2	010010		1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					397.70	25	25	25																												25		25					25		25				25			25			25			
S5617	163	0		29	10	S5617_163_0	3	1	Preferred Generic	1	2	001001		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	163	0		29	10	S5617_163_0	3	2	Non-Preferred Generic	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		8.00	16.00	24.00																													8.00		20.00					8.00		24.00					8.00			.25	8.00		.25	8.00				
S5617	163	0		29	10	S5617_163_0	3	5	Specialty Tier	1	2	010010		1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					400.12	25	25	25																												25		25					25		25				25			25			25			
S5617	163	0		29	10	S5617_163_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		84.00	168.00	252.00																													84.00		210.00					84.00		252.00					84.00			2.70	84.00		2.70	84.00				
S5617	163	0		29	10	S5617_163_0	3	3	Preferred Brand	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		36.00	72.00	108.00																													36.00		90.00					36.00		108.00					36.00			1.16	36.00		1.16	36.00				
S5617	172	0		29	10	S5617_172_0	2	1	Preferred Generic	1	4	001001	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	172	0		29	10	S5617_172_0	2	2	Non-Preferred Generic	1	4	000101	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		10.00	20.00	30.00																													10.00		25.00					10.00		30.00					10.00			.32	10.00		.32	10.00				
S5617	172	0		29	10	S5617_172_0	2	3	Preferred Brand	1	4	000101	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		45.00	90.00	135.00																													45.00		112.50					45.00		135.00					45.00			1.45	45.00		1.45	45.00				
S5617	172	0		29	10	S5617_172_0	2	4	Non-Preferred Brand	1	4	100100	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		90.00	180.00	270.00																													90.00		225.00					90.00		270.00					90.00			2.90	90.00		2.90	90.00				
S5617	172	0		29	10	S5617_172_0	2	5	Specialty Tier	1	4	010010	1	1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					529.61	33	33	33																												33		33					33		33				33			33			33			
S5617	172	0		29	10	S5617_172_0	2	1	Preferred Generic	3	4	001001	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00		1		
S5617	176	0		29	10	S5617_176_0	2	2	Non-Preferred Generic	1	4	000101	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		10.00	20.00	30.00																													10.00		25.00					10.00		30.00					10.00			.32	10.00		.32	10.00				
S5617	176	0		29	10	S5617_176_0	2	3	Preferred Brand	1	4	000101	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		45.00	90.00	135.00																													45.00		112.50					45.00		135.00					45.00			1.45	45.00		1.45	45.00				
S5617	176	0		29	10	S5617_176_0	2	4	Non-Preferred Brand	1	4	100100	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		90.00	180.00	270.00																													90.00		225.00					90.00		270.00					90.00			2.90	90.00		2.90	90.00				
S5617	176	0		29	10	S5617_176_0	2	5	Specialty Tier	1	4	010010	1	1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					434.39	33	33	33																												33		33					33		33				33			33			33			
S5617	176	0		29	10	S5617_176_0	2	1	Preferred Generic	3	4	001001	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00		1		
S5617	176	0		29	10	S5617_176_0	2	1	Preferred Generic	1	4	001001	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	177	0		29	10	S5617_177_0	2	1	Preferred Generic	3	4	001001	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00		1		
S5617	177	0		29	10	S5617_177_0	2	5	Specialty Tier	1	4	010010	1	1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					507.64	33	33	33																												33		33					33		33				33			33			33			
S5617	177	0		29	10	S5617_177_0	2	4	Non-Preferred Brand	1	4	100100	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		90.00	180.00	270.00																													90.00		225.00					90.00		270.00					90.00			2.90	90.00		2.90	90.00				
S5617	177	0		29	10	S5617_177_0	2	3	Preferred Brand	1	4	000101	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		45.00	90.00	135.00																													45.00		112.50					45.00		135.00					45.00			1.45	45.00		1.45	45.00				
S5617	177	0		29	10	S5617_177_0	2	2	Non-Preferred Generic	1	4	000101	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		10.00	20.00	30.00																													10.00		25.00					10.00		30.00					10.00			.32	10.00		.32	10.00				
S5617	177	0		29	10	S5617_177_0	2	1	Preferred Generic	1	4	001001	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	178	0		29	10	S5617_178_0	2	1	Preferred Generic	3	4	001001	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00		1		
S5617	178	0		29	10	S5617_178_0	2	5	Specialty Tier	1	4	010010	1	1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					507.64	33	33	33																												33		33					33		33				33			33			33			
S5617	178	0		29	10	S5617_178_0	2	4	Non-Preferred Brand	1	4	100100	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		90.00	180.00	270.00																													90.00		225.00					90.00		270.00					90.00			2.90	90.00		2.90	90.00				
S5617	178	0		29	10	S5617_178_0	2	3	Preferred Brand	1	4	000101	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		45.00	90.00	135.00																													45.00		112.50					45.00		135.00					45.00			1.45	45.00		1.45	45.00				
S5617	178	0		29	10	S5617_178_0	2	2	Non-Preferred Generic	1	4	000101	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		10.00	20.00	30.00																													10.00		25.00					10.00		30.00					10.00			.32	10.00		.32	10.00				
S5617	178	0		29	10	S5617_178_0	2	1	Preferred Generic	1	4	001001	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	179	0		29	10	S5617_179_0	2	1	Preferred Generic	1	4	001001	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	179	0		29	10	S5617_179_0	2	2	Non-Preferred Generic	1	4	000101	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		10.00	20.00	30.00																													10.00		25.00					10.00		30.00					10.00			.32	10.00		.32	10.00				
S5617	179	0		29	10	S5617_179_0	2	3	Preferred Brand	1	4	000101	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		45.00	90.00	135.00																													45.00		112.50					45.00		135.00					45.00			1.45	45.00		1.45	45.00				
S5617	179	0		29	10	S5617_179_0	2	4	Non-Preferred Brand	1	4	100100	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		90.00	180.00	270.00																													90.00		225.00					90.00		270.00					90.00			2.90	90.00		2.90	90.00				
S5617	179	0		29	10	S5617_179_0	2	5	Specialty Tier	1	4	010010	1	1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					507.64	33	33	33																												33		33					33		33				33			33			33			
S5617	179	0		29	10	S5617_179_0	2	1	Preferred Generic	3	4	001001	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00		1		
S5617	181	0		29	10	S5617_181_0	2	1	Preferred Generic	1	4	001001	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	181	0		29	10	S5617_181_0	2	2	Non-Preferred Generic	1	4	000101	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		10.00	20.00	30.00																													10.00		25.00					10.00		30.00					10.00			.32	10.00		.32	10.00				
S5617	181	0		29	10	S5617_181_0	2	3	Preferred Brand	1	4	000101	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		45.00	90.00	135.00																													45.00		112.50					45.00		135.00					45.00			1.45	45.00		1.45	45.00				
S5617	181	0		29	10	S5617_181_0	2	4	Non-Preferred Brand	1	4	100100	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		90.00	180.00	270.00																													90.00		225.00					90.00		270.00					90.00			2.90	90.00		2.90	90.00				
S5617	181	0		29	10	S5617_181_0	2	5	Specialty Tier	1	4	010010	1	1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					507.64	33	33	33																												33		33					33		33				33			33			33			
S5617	181	0		29	10	S5617_181_0	2	1	Preferred Generic	3	4	001001	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00		1		
S5617	182	0		29	10	S5617_182_0	2	3	Preferred Brand	1	4	000101	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		45.00	90.00	135.00																													45.00		112.50					45.00		135.00					45.00			1.45	45.00		1.45	45.00				
S5617	182	0		29	10	S5617_182_0	2	4	Non-Preferred Brand	1	4	100100	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		90.00	180.00	270.00																													90.00		225.00					90.00		270.00					90.00			2.90	90.00		2.90	90.00				
S5617	182	0		29	10	S5617_182_0	2	1	Preferred Generic	1	4	001001	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	182	0		29	10	S5617_182_0	2	2	Non-Preferred Generic	1	4	000101	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		10.00	20.00	30.00																													10.00		25.00					10.00		30.00					10.00			.32	10.00		.32	10.00				
S5617	182	0		29	10	S5617_182_0	2	5	Specialty Tier	1	4	010010	1	1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					507.64	33	33	33																												33		33					33		33				33			33			33			
S5617	182	0		29	10	S5617_182_0	2	1	Preferred Generic	3	4	001001	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00		1		
S5617	183	0		29	10	S5617_183_0	2	1	Preferred Generic	3	4	001001	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00		1		
S5617	183	0		29	10	S5617_183_0	2	3	Preferred Brand	1	4	000101	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		45.00	90.00	135.00																													45.00		112.50					45.00		135.00					45.00			1.45	45.00		1.45	45.00				
S5617	183	0		29	10	S5617_183_0	2	2	Non-Preferred Generic	1	4	000101	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		10.00	20.00	30.00																													10.00		25.00					10.00		30.00					10.00			.32	10.00		.32	10.00				
S5617	183	0		29	10	S5617_183_0	2	1	Preferred Generic	1	4	001001	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	183	0		29	10	S5617_183_0	2	4	Non-Preferred Brand	1	4	100100	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		90.00	180.00	270.00																													90.00		225.00					90.00		270.00					90.00			2.90	90.00		2.90	90.00				
S5617	183	0		29	10	S5617_183_0	2	5	Specialty Tier	1	4	010010	1	1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					507.64	33	33	33																												33		33					33		33				33			33			33			
S5617	184	0		29	10	S5617_184_0	2	1	Preferred Generic	1	4	001001	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	184	0		29	10	S5617_184_0	2	3	Preferred Brand	1	4	000101	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		45.00	90.00	135.00																													45.00		112.50					45.00		135.00					45.00			1.45	45.00		1.45	45.00				
S5617	184	0		29	10	S5617_184_0	2	4	Non-Preferred Brand	1	4	100100	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		90.00	180.00	270.00																													90.00		225.00					90.00		270.00					90.00			2.90	90.00		2.90	90.00				
S5617	184	0		29	10	S5617_184_0	2	5	Specialty Tier	1	4	010010	1	1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					507.64	33	33	33																												33		33					33		33				33			33			33			
S5617	184	0		29	10	S5617_184_0	2	1	Preferred Generic	3	4	001001	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00		1		
S5617	184	0		29	10	S5617_184_0	2	2	Non-Preferred Generic	1	4	000101	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		10.00	20.00	30.00																													10.00		25.00					10.00		30.00					10.00			.32	10.00		.32	10.00				
S5617	185	0		29	10	S5617_185_0	2	4	Non-Preferred Brand	1	4	100100	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		90.00	180.00	270.00																													90.00		225.00					90.00		270.00					90.00			2.90	90.00		2.90	90.00				
S5617	185	0		29	10	S5617_185_0	2	5	Specialty Tier	1	4	010010	1	1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					507.64	33	33	33																												33		33					33		33				33			33			33			
S5617	185	0		29	10	S5617_185_0	2	1	Preferred Generic	3	4	001001	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00		1		
S5617	185	0		29	10	S5617_185_0	2	2	Non-Preferred Generic	1	4	000101	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		10.00	20.00	30.00																													10.00		25.00					10.00		30.00					10.00			.32	10.00		.32	10.00				
S5617	185	0		29	10	S5617_185_0	2	3	Preferred Brand	1	4	000101	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		45.00	90.00	135.00																													45.00		112.50					45.00		135.00					45.00			1.45	45.00		1.45	45.00				
S5617	185	0		29	10	S5617_185_0	2	1	Preferred Generic	1	4	001001	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	187	0		29	10	S5617_187_0	2	3	Preferred Brand	1	4	000101	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		45.00	90.00	135.00																													45.00		112.50					45.00		135.00					45.00			1.45	45.00		1.45	45.00				
S5617	187	0		29	10	S5617_187_0	2	2	Non-Preferred Generic	1	4	000101	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		10.00	20.00	30.00																													10.00		25.00					10.00		30.00					10.00			.32	10.00		.32	10.00				
S5617	187	0		29	10	S5617_187_0	2	1	Preferred Generic	1	4	001001	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	187	0		29	10	S5617_187_0	2	5	Specialty Tier	1	4	010010	1	1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					507.64	33	33	33																												33		33					33		33				33			33			33			
S5617	187	0		29	10	S5617_187_0	2	1	Preferred Generic	3	4	001001	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00		1		
S5617	187	0		29	10	S5617_187_0	2	4	Non-Preferred Brand	1	4	100100	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		90.00	180.00	270.00																													90.00		225.00					90.00		270.00					90.00			2.90	90.00		2.90	90.00				
S5617	188	0		29	10	S5617_188_0	2	1	Preferred Generic	1	4	001001	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	188	0		29	10	S5617_188_0	2	2	Non-Preferred Generic	1	4	000101	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		10.00	20.00	30.00																													10.00		25.00					10.00		30.00					10.00			.32	10.00		.32	10.00				
S5617	188	0		29	10	S5617_188_0	2	4	Non-Preferred Brand	1	4	100100	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		90.00	180.00	270.00																													90.00		225.00					90.00		270.00					90.00			2.90	90.00		2.90	90.00				
S5617	188	0		29	10	S5617_188_0	2	5	Specialty Tier	1	4	010010	1	1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					507.64	33	33	33																												33		33					33		33				33			33			33			
S5617	188	0		29	10	S5617_188_0	2	1	Preferred Generic	3	4	001001	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00		1		
S5617	188	0		29	10	S5617_188_0	2	3	Preferred Brand	1	4	000101	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		45.00	90.00	135.00																													45.00		112.50					45.00		135.00					45.00			1.45	45.00		1.45	45.00				
S5617	189	0		29	10	S5617_189_0	2	1	Preferred Generic	1	4	001001	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	189	0		29	10	S5617_189_0	2	1	Preferred Generic	3	4	001001	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00		1		
S5617	189	0		29	10	S5617_189_0	2	3	Preferred Brand	1	4	000101	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		45.00	90.00	135.00																													45.00		112.50					45.00		135.00					45.00			1.45	45.00		1.45	45.00				
S5617	189	0		29	10	S5617_189_0	2	2	Non-Preferred Generic	1	4	000101	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		10.00	20.00	30.00																													10.00		25.00					10.00		30.00					10.00			.32	10.00		.32	10.00				
S5617	189	0		29	10	S5617_189_0	2	5	Specialty Tier	1	4	010010	1	1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					507.64	33	33	33																												33		33					33		33				33			33			33			
S5617	189	0		29	10	S5617_189_0	2	4	Non-Preferred Brand	1	4	100100	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		90.00	180.00	270.00																													90.00		225.00					90.00		270.00					90.00			2.90	90.00		2.90	90.00				
S5617	192	0		29	10	S5617_192_0	2	3	Preferred Brand	1	4	000101	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		45.00	90.00	135.00																													45.00		112.50					45.00		135.00					45.00			1.45	45.00		1.45	45.00				
S5617	192	0		29	10	S5617_192_0	2	2	Non-Preferred Generic	1	4	000101	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		10.00	20.00	30.00																													10.00		25.00					10.00		30.00					10.00			.32	10.00		.32	10.00				
S5617	192	0		29	10	S5617_192_0	2	1	Preferred Generic	1	4	001001	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	192	0		29	10	S5617_192_0	2	4	Non-Preferred Brand	1	4	100100	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		90.00	180.00	270.00																													90.00		225.00					90.00		270.00					90.00			2.90	90.00		2.90	90.00				
S5617	192	0		29	10	S5617_192_0	2	5	Specialty Tier	1	4	010010	1	1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					507.64	33	33	33																												33		33					33		33				33			33			33			
S5617	192	0		29	10	S5617_192_0	2	1	Preferred Generic	3	4	001001	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00		1		
S5617	195	0		29	10	S5617_195_0	2	1	Preferred Generic	3	4	001001	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00		1		
S5617	195	0		29	10	S5617_195_0	2	5	Specialty Tier	1	4	010010	1	1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					507.64	33	33	33																												33		33					33		33				33			33			33			
S5617	195	0		29	10	S5617_195_0	2	4	Non-Preferred Brand	1	4	100100	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		90.00	180.00	270.00																													90.00		225.00					90.00		270.00					90.00			2.90	90.00		2.90	90.00				
S5617	195	0		29	10	S5617_195_0	2	3	Preferred Brand	1	4	000101	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		45.00	90.00	135.00																													45.00		112.50					45.00		135.00					45.00			1.45	45.00		1.45	45.00				
S5617	195	0		29	10	S5617_195_0	2	1	Preferred Generic	1	4	001001	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	195	0		29	10	S5617_195_0	2	2	Non-Preferred Generic	1	4	000101	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		10.00	20.00	30.00																													10.00		25.00					10.00		30.00					10.00			.32	10.00		.32	10.00				
S5617	198	0		29	10	S5617_198_0	2	1	Preferred Generic	3	4	001001	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00		1		
S5617	198	0		29	10	S5617_198_0	2	5	Specialty Tier	1	4	010010	1	1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					507.64	33	33	33																												33		33					33		33				33			33			33			
S5617	198	0		29	10	S5617_198_0	2	4	Non-Preferred Brand	1	4	100100	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		90.00	180.00	270.00																													90.00		225.00					90.00		270.00					90.00			2.90	90.00		2.90	90.00				
S5617	198	0		29	10	S5617_198_0	2	3	Preferred Brand	1	4	000101	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		45.00	90.00	135.00																													45.00		112.50					45.00		135.00					45.00			1.45	45.00		1.45	45.00				
S5617	198	0		29	10	S5617_198_0	2	2	Non-Preferred Generic	1	4	000101	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		10.00	20.00	30.00																													10.00		25.00					10.00		30.00					10.00			.32	10.00		.32	10.00				
S5617	198	0		29	10	S5617_198_0	2	1	Preferred Generic	1	4	001001	1	2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	214	0		29	10	S5617_214_0	5	2	Non-Preferred Generic	1	3	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		8.00	16.00	24.00																													8.00		20.00					8.00		24.00					8.00			.25	8.00		.25	8.00				
S5617	214	0		29	10	S5617_214_0	5	1	Preferred Generic	1	3	001001		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	214	0		29	10	S5617_214_0	5	4	Non-Preferred Brand	1	3	100100		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		91.00	182.00	273.00																													91.00		227.50					91.00		273.00					91.00			2.93	91.00		2.93	91.00				
S5617	214	0		29	10	S5617_214_0	5	5	Specialty Tier	1	3	010010		1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					426.37	25	25	25																												25		25					25		25				25			25			25			
S5617	214	0		29	10	S5617_214_0	5	3	Preferred Brand	1	3	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		26.00	52.00	78.00																													26.00		65.00					26.00		78.00					26.00			.83	26.00		.83	26.00				
S5617	215	0		29	10	S5617_215_0	3	1	Preferred Generic	1	2	001001		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	215	0		29	10	S5617_215_0	3	2	Non-Preferred Generic	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		8.00	16.00	24.00																													8.00		20.00					8.00		24.00					8.00			.25	8.00		.25	8.00				
S5617	215	0		29	10	S5617_215_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		83.00	166.00	249.00																													83.00		207.50					83.00		249.00					83.00			2.67	83.00		2.67	83.00				
S5617	215	0		29	10	S5617_215_0	3	5	Specialty Tier	1	2	010010		1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					415.82	25	25	25																												25		25					25		25				25			25			25			
S5617	215	0		29	10	S5617_215_0	3	3	Preferred Brand	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		34.00	68.00	102.00																													34.00		85.00					34.00		102.00					34.00			1.09	34.00		1.09	34.00				
S5617	216	0		29	10	S5617_216_0	3	3	Preferred Brand	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		32.00	64.00	96.00																													32.00		80.00					32.00		96.00					32.00			1.03	32.00		1.03	32.00				
S5617	216	0		29	10	S5617_216_0	3	5	Specialty Tier	1	2	010010		1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					372.26	25	25	25																												25		25					25		25				25			25			25			
S5617	216	0		29	10	S5617_216_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		81.00	162.00	243.00																													81.00		202.50					81.00		243.00					81.00			2.61	81.00		2.61	81.00				
S5617	216	0		29	10	S5617_216_0	3	2	Non-Preferred Generic	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		8.00	16.00	24.00																													8.00		20.00					8.00		24.00					8.00			.25	8.00		.25	8.00				
S5617	216	0		29	10	S5617_216_0	3	1	Preferred Generic	1	2	001001		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	217	0		29	10	S5617_217_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		81.00	162.00	243.00																													81.00		202.50					81.00		243.00					81.00			2.61	81.00		2.61	81.00				
S5617	217	0		29	10	S5617_217_0	3	5	Specialty Tier	1	2	010010		1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					422.26	25	25	25																												25		25					25		25				25			25			25			
S5617	217	0		29	10	S5617_217_0	3	3	Preferred Brand	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		35.00	70.00	105.00																													35.00		87.50					35.00		105.00					35.00			1.12	35.00		1.12	35.00				
S5617	217	0		29	10	S5617_217_0	3	2	Non-Preferred Generic	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		8.00	16.00	24.00																													8.00		20.00					8.00		24.00					8.00			.25	8.00		.25	8.00				
S5617	217	0		29	10	S5617_217_0	3	1	Preferred Generic	1	2	001001		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	218	0		29	10	S5617_218_0	5	3	Preferred Brand	1	3	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		27.00	54.00	81.00																													27.00		67.50					27.00		81.00					27.00			.87	27.00		.87	27.00				
S5617	218	0		29	10	S5617_218_0	5	5	Specialty Tier	1	3	010010		1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					435.43	25	25	25																												25		25					25		25				25			25			25			
S5617	218	0		29	10	S5617_218_0	5	4	Non-Preferred Brand	1	3	100100		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		83.00	166.00	249.00																													83.00		207.50					83.00		249.00					83.00			2.67	83.00		2.67	83.00				
S5617	218	0		29	10	S5617_218_0	5	2	Non-Preferred Generic	1	3	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		8.00	16.00	24.00																													8.00		20.00					8.00		24.00					8.00			.25	8.00		.25	8.00				
S5617	218	0		29	10	S5617_218_0	5	1	Preferred Generic	1	3	001001		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	219	0		29	10	S5617_219_0	5	4	Non-Preferred Brand	1	3	100100		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		88.00	176.00	264.00																													88.00		220.00					88.00		264.00					88.00			2.83	88.00		2.83	88.00				
S5617	219	0		29	10	S5617_219_0	5	5	Specialty Tier	1	3	010010		1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					427.61	25	25	25																												25		25					25		25				25			25			25			
S5617	219	0		29	10	S5617_219_0	5	3	Preferred Brand	1	3	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		24.00	48.00	72.00																													24.00		60.00					24.00		72.00					24.00			.77	24.00		.77	24.00				
S5617	219	0		29	10	S5617_219_0	5	2	Non-Preferred Generic	1	3	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		8.00	16.00	24.00																													8.00		20.00					8.00		24.00					8.00			.25	8.00		.25	8.00				
S5617	219	0		29	10	S5617_219_0	5	1	Preferred Generic	1	3	001001		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	220	0		29	10	S5617_220_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		75.00	150.00	225.00																													75.00		187.50					75.00		225.00					75.00			2.41	75.00		2.41	75.00				
S5617	220	0		29	10	S5617_220_0	3	3	Preferred Brand	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		29.00	58.00	87.00																													29.00		72.50					29.00		87.00					29.00			.93	29.00		.93	29.00				
S5617	220	0		29	10	S5617_220_0	3	5	Specialty Tier	1	2	010010		1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					370.41	25	25	25																												25		25					25		25				25			25			25			
S5617	220	0		29	10	S5617_220_0	3	2	Non-Preferred Generic	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		8.00	16.00	24.00																													8.00		20.00					8.00		24.00					8.00			.25	8.00		.25	8.00				
S5617	220	0		29	10	S5617_220_0	3	1	Preferred Generic	1	2	001001		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	221	0		29	10	S5617_221_0	3	5	Specialty Tier	1	2	010010		1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					363.52	25	25	25																												25		25					25		25				25			25			25			
S5617	221	0		29	10	S5617_221_0	3	1	Preferred Generic	1	2	001001		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	221	0		29	10	S5617_221_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		83.00	166.00	249.00																													83.00		207.50					83.00		249.00					83.00			2.67	83.00		2.67	83.00				
S5617	221	0		29	10	S5617_221_0	3	3	Preferred Brand	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		33.00	66.00	99.00																													33.00		82.50					33.00		99.00					33.00			1.06	33.00		1.06	33.00				
S5617	221	0		29	10	S5617_221_0	3	2	Non-Preferred Generic	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		8.00	16.00	24.00																													8.00		20.00					8.00		24.00					8.00			.25	8.00		.25	8.00				
S5617	222	0		29	10	S5617_222_0	3	5	Specialty Tier	1	2	010010		1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					412.37	25	25	25																												25		25					25		25				25			25			25			
S5617	222	0		29	10	S5617_222_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		81.00	162.00	243.00																													81.00		202.50					81.00		243.00					81.00			2.61	81.00		2.61	81.00				
S5617	222	0		29	10	S5617_222_0	3	2	Non-Preferred Generic	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		8.00	16.00	24.00																													8.00		20.00					8.00		24.00					8.00			.25	8.00		.25	8.00				
S5617	222	0		29	10	S5617_222_0	3	3	Preferred Brand	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		33.00	66.00	99.00																													33.00		82.50					33.00		99.00					33.00			1.06	33.00		1.06	33.00				
S5617	222	0		29	10	S5617_222_0	3	1	Preferred Generic	1	2	001001		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	223	0		29	10	S5617_223_0	5	1	Preferred Generic	1	3	001001		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	223	0		29	10	S5617_223_0	5	5	Specialty Tier	1	3	010010		1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					421.15	25	25	25																												25		25					25		25				25			25			25			
S5617	223	0		29	10	S5617_223_0	5	4	Non-Preferred Brand	1	3	100100		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		80.00	160.00	240.00																													80.00		200.00					80.00		240.00					80.00			2.58	80.00		2.58	80.00				
S5617	223	0		29	10	S5617_223_0	5	2	Non-Preferred Generic	1	3	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		8.00	16.00	24.00																													8.00		20.00					8.00		24.00					8.00			.25	8.00		.25	8.00				
S5617	223	0		29	10	S5617_223_0	5	3	Preferred Brand	1	3	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		28.00	56.00	84.00																													28.00		70.00					28.00		84.00					28.00			.90	28.00		.90	28.00				
S5617	224	0		29	10	S5617_224_0	3	5	Specialty Tier	1	2	010010		1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					399.78	25	25	25																												25		25					25		25				25			25			25			
S5617	224	0		29	10	S5617_224_0	3	1	Preferred Generic	1	2	001001		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	224	0		29	10	S5617_224_0	3	2	Non-Preferred Generic	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		8.00	16.00	24.00																													8.00		20.00					8.00		24.00					8.00			.25	8.00		.25	8.00				
S5617	224	0		29	10	S5617_224_0	3	3	Preferred Brand	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		32.00	64.00	96.00																													32.00		80.00					32.00		96.00					32.00			1.03	32.00		1.03	32.00				
S5617	224	0		29	10	S5617_224_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		83.00	166.00	249.00																													83.00		207.50					83.00		249.00					83.00			2.67	83.00		2.67	83.00				
S5617	225	0		29	10	S5617_225_0	3	2	Non-Preferred Generic	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		8.00	16.00	24.00																													8.00		20.00					8.00		24.00					8.00			.25	8.00		.25	8.00				
S5617	225	0		29	10	S5617_225_0	3	1	Preferred Generic	1	2	001001		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	225	0		29	10	S5617_225_0	3	3	Preferred Brand	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		28.00	56.00	84.00																													28.00		70.00					28.00		84.00					28.00			.90	28.00		.90	28.00				
S5617	225	0		29	10	S5617_225_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		71.00	142.00	213.00																													71.00		177.50					71.00		213.00					71.00			2.29	71.00		2.29	71.00				
S5617	225	0		29	10	S5617_225_0	3	5	Specialty Tier	1	2	010010		1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					420.70	25	25	25																												25		25					25		25				25			25			25			
S5617	226	0		29	10	S5617_226_0	5	2	Non-Preferred Generic	1	3	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		8.00	16.00	24.00																													8.00		20.00					8.00		24.00					8.00			.25	8.00		.25	8.00				
S5617	226	0		29	10	S5617_226_0	5	1	Preferred Generic	1	3	001001		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	226	0		29	10	S5617_226_0	5	3	Preferred Brand	1	3	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		23.00	46.00	69.00																													23.00		57.50					23.00		69.00					23.00			.74	23.00		.74	23.00				
S5617	226	0		29	10	S5617_226_0	5	5	Specialty Tier	1	3	010010		1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					406.55	25	25	25																												25		25					25		25				25			25			25			
S5617	226	0		29	10	S5617_226_0	5	4	Non-Preferred Brand	1	3	100100		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		79.00	158.00	237.00																													79.00		197.50					79.00		237.00					79.00			2.54	79.00		2.54	79.00				
S5617	227	0		29	10	S5617_227_0	3	1	Preferred Generic	1	2	001001		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		0.00	0.00	0.00																													0.00		0.00					0.00		0.00					0.00			0.00	0.00		0.00	0.00				
S5617	227	0		29	10	S5617_227_0	3	2	Non-Preferred Generic	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		8.00	16.00	24.00																													8.00		20.00					8.00		24.00					8.00			.25	8.00		.25	8.00				
S5617	227	0		29	10	S5617_227_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		52.00	104.00	156.00																													52.00		130.00					52.00		156.00					52.00			1.67	52.00		1.67	52.00				
S5617	227	0		29	10	S5617_227_0	3	3	Preferred Brand	1	2	000101		2	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1		22.00	44.00	66.00																													22.00		55.00					22.00		66.00					22.00			.70	22.00		.70	22.00				
S5617	227	0		29	10	S5617_227_0	3	5	Specialty Tier	1	2	010010		1	111100000001000101101111	30	60	90							1				30		90	30		90		10	31	1	31	1					393.10	25	25	25																												25		25					25		25				25			25			25			
S5660	104	0		29	10	S5660_104_0	3	1	Preferred Generic	1	2	001010		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		4.00		12.00																															8.00							12.00				4.00					4.00			4.00				
S5660	104	0		29	10	S5660_104_0	3	2	Non-Preferred Generic	1	2	000110		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		7.00		21.00																															14.00							21.00				7.00					7.00			7.00				
S5660	104	0		29	10	S5660_104_0	3	3	Preferred Brand	1	2	010001		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					44.00	25		25																														25							25			25				25			25			
S5660	104	0		29	10	S5660_104_0	3	4	Non-Preferred Brand	1	2	110000		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					96.00	50		50																														50							50			50				50			50			
S5660	104	0		29	10	S5660_104_0	3	5	Specialty Tier	1	2	010010		1	110000000010000100100111	31													31			31			31		31	7	31	7					275.00	25																														25							25					25				25			25			
S5660	105	0		29	10	S5660_105_0	1	1	Preferred Generic	1	2	001010		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		4.00		12.00																															8.00							12.00				4.00					4.00			4.00				
S5660	105	0		29	10	S5660_105_0	1	2	Non-Preferred Generic	1	2	000110		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		7.00		21.00																															14.00							21.00				7.00					7.00			7.00				
S5660	105	0		29	10	S5660_105_0	1	5	Specialty Tier	1	2	010010		1	110000000010000100100111	31													31			31			31		31	7	31	7					285.00	25																														25							25					25				25			25			
S5660	105	0		29	10	S5660_105_0	1	4	Non-Preferred Brand	1	2	110000		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					103.00	50		50																														50							50			50				50			50			
S5660	105	0		29	10	S5660_105_0	1	3	Preferred Brand	1	2	010001		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					43.00	25		25																														25							25			25				25			25			
S5660	106	0		29	10	S5660_106_0	2	2	Non-Preferred Generic	1	2	000110		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		7.00		21.00																															14.00							21.00				7.00					7.00			7.00				
S5660	106	0		29	10	S5660_106_0	2	3	Preferred Brand	1	2	010001		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					41.00	25		25																														25							25			25				25			25			
S5660	106	0		29	10	S5660_106_0	2	4	Non-Preferred Brand	1	2	110000		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					103.00	44		44																														44							44			44				44			44			
S5660	106	0		29	10	S5660_106_0	2	5	Specialty Tier	1	2	010010		1	110000000010000100100111	31													31			31			31		31	7	31	7					271.00	25																														25							25					25				25			25			
S5660	106	0		29	10	S5660_106_0	2	1	Preferred Generic	1	2	001010		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		4.00		12.00																															8.00							12.00				4.00					4.00			4.00				
S5660	107	0		29	10	S5660_107_0	2	4	Non-Preferred Brand	1	2	110000		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					104.00	44		44																														44							44			44				44			44			
S5660	107	0		29	10	S5660_107_0	2	3	Preferred Brand	1	2	010001		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					43.00	25		25																														25							25			25				25			25			
S5660	107	0		29	10	S5660_107_0	2	2	Non-Preferred Generic	1	2	000110		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		7.00		21.00																															14.00							21.00				7.00					7.00			7.00				
S5660	107	0		29	10	S5660_107_0	2	1	Preferred Generic	1	2	001010		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		4.00		12.00																															8.00							12.00				4.00					4.00			4.00				
S5660	107	0		29	10	S5660_107_0	2	5	Specialty Tier	1	2	010010		1	110000000010000100100111	31													31			31			31		31	7	31	7					267.00	25																														25							25					25				25			25			
S5660	108	0		29	10	S5660_108_0	2	4	Non-Preferred Brand	1	2	110000		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					102.00	46		46																														46							46			46				46			46			
S5660	108	0		29	10	S5660_108_0	2	3	Preferred Brand	1	2	010001		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					42.00	25		25																														25							25			25				25			25			
S5660	108	0		29	10	S5660_108_0	2	2	Non-Preferred Generic	1	2	000110		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		6.00		18.00																															12.00							18.00				6.00					6.00			6.00				
S5660	108	0		29	10	S5660_108_0	2	1	Preferred Generic	1	2	001010		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		4.00		12.00																															8.00							12.00				4.00					4.00			4.00				
S5660	108	0		29	10	S5660_108_0	2	5	Specialty Tier	1	2	010010		1	110000000010000100100111	31													31			31			31		31	7	31	7					277.00	25																														25							25					25				25			25			
S5660	109	0		29	10	S5660_109_0	1	2	Non-Preferred Generic	1	2	000110		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		7.00		21.00																															14.00							21.00				7.00					7.00			7.00				
S5660	109	0		29	10	S5660_109_0	1	3	Preferred Brand	1	2	010001		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					40.00	25		25																														25							25			25				25			25			
S5660	109	0		29	10	S5660_109_0	1	4	Non-Preferred Brand	1	2	110000		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					88.00	50		50																														50							50			50				50			50			
S5660	109	0		29	10	S5660_109_0	1	5	Specialty Tier	1	2	010010		1	110000000010000100100111	31													31			31			31		31	7	31	7					283.00	25																														25							25					25				25			25			
S5660	109	0		29	10	S5660_109_0	1	1	Preferred Generic	1	2	001010		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		4.00		12.00																															8.00							12.00				4.00					4.00			4.00				
S5660	110	0		29	10	S5660_110_0	2	4	Non-Preferred Brand	1	2	110000		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					104.00	47		47																														47							47			47				47			47			
S5660	110	0		29	10	S5660_110_0	2	3	Preferred Brand	1	2	010001		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					41.00	25		25																														25							25			25				25			25			
S5660	110	0		29	10	S5660_110_0	2	1	Preferred Generic	1	2	001010		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		4.00		12.00																															8.00							12.00				4.00					4.00			4.00				
S5660	110	0		29	10	S5660_110_0	2	2	Non-Preferred Generic	1	2	000110		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		6.00		18.00																															12.00							18.00				6.00					6.00			6.00				
S5660	110	0		29	10	S5660_110_0	2	5	Specialty Tier	1	2	010010		1	110000000010000100100111	31													31			31			31		31	7	31	7					283.00	25																														25							25					25				25			25			
S5660	111	0		29	10	S5660_111_0	1	1	Preferred Generic	1	2	001010		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		4.00		12.00																															8.00							12.00				4.00					4.00			4.00				
S5660	111	0		29	10	S5660_111_0	1	2	Non-Preferred Generic	1	2	000110		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		7.00		21.00																															14.00							21.00				7.00					7.00			7.00				
S5660	111	0		29	10	S5660_111_0	1	3	Preferred Brand	1	2	010001		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					42.00	25		25																														25							25			25				25			25			
S5660	111	0		29	10	S5660_111_0	1	4	Non-Preferred Brand	1	2	110000		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					103.00	50		50																														50							50			50				50			50			
S5660	111	0		29	10	S5660_111_0	1	5	Specialty Tier	1	2	010010		1	110000000010000100100111	31													31			31			31		31	7	31	7					268.00	25																														25							25					25				25			25			
S5660	112	0		29	10	S5660_112_0	1	5	Specialty Tier	1	2	010010		1	110000000010000100100111	31													31			31			31		31	7	31	7					280.00	25																														25							25					25				25			25			
S5660	112	0		29	10	S5660_112_0	1	4	Non-Preferred Brand	1	2	110000		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					91.00	50		50																														50							50			50				50			50			
S5660	112	0		29	10	S5660_112_0	1	3	Preferred Brand	1	2	010001		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					41.00	25		25																														25							25			25				25			25			
S5660	112	0		29	10	S5660_112_0	1	1	Preferred Generic	1	2	001010		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		4.00		12.00																															8.00							12.00				4.00					4.00			4.00				
S5660	112	0		29	10	S5660_112_0	1	2	Non-Preferred Generic	1	2	000110		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		6.00		18.00																															12.00							18.00				6.00					6.00			6.00				
S5660	113	0		29	10	S5660_113_0	1	5	Specialty Tier	1	2	010010		1	110000000010000100100111	31													31			31			31		31	7	31	7					285.00	25																														25							25					25				25			25			
S5660	113	0		29	10	S5660_113_0	1	1	Preferred Generic	1	2	001010		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		4.00		12.00																															8.00							12.00				4.00					4.00			4.00				
S5660	113	0		29	10	S5660_113_0	1	4	Non-Preferred Brand	1	2	110000		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					97.00	50		50																														50							50			50				50			50			
S5660	113	0		29	10	S5660_113_0	1	3	Preferred Brand	1	2	010001		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					39.00	25		25																														25							25			25				25			25			
S5660	113	0		29	10	S5660_113_0	1	2	Non-Preferred Generic	1	2	000110		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		6.00		18.00																															12.00							18.00				6.00					6.00			6.00				
S5660	114	0		29	10	S5660_114_0	1	5	Specialty Tier	1	2	010010		1	110000000010000100100111	31													31			31			31		31	7	31	7					283.00	25																														25							25					25				25			25			
S5660	114	0		29	10	S5660_114_0	1	1	Preferred Generic	1	2	001010		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		4.00		12.00																															8.00							12.00				4.00					4.00			4.00				
S5660	114	0		29	10	S5660_114_0	1	4	Non-Preferred Brand	1	2	110000		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					98.00	50		50																														50							50			50				50			50			
S5660	114	0		29	10	S5660_114_0	1	2	Non-Preferred Generic	1	2	000110		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		6.00		18.00																															12.00							18.00				6.00					6.00			6.00				
S5660	114	0		29	10	S5660_114_0	1	3	Preferred Brand	1	2	010001		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					42.00	25		25																														25							25			25				25			25			
S5660	115	0		29	10	S5660_115_0	2	2	Non-Preferred Generic	1	2	000110		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		6.00		18.00																															12.00							18.00				6.00					6.00			6.00				
S5660	115	0		29	10	S5660_115_0	2	3	Preferred Brand	1	2	010001		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					46.00	25		25																														25							25			25				25			25			
S5660	115	0		29	10	S5660_115_0	2	5	Specialty Tier	1	2	010010		1	110000000010000100100111	31													31			31			31		31	7	31	7					324.00	25																														25							25					25				25			25			
S5660	115	0		29	10	S5660_115_0	2	4	Non-Preferred Brand	1	2	110000		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					103.00	48		48																														48							48			48				48			48			
S5660	115	0		29	10	S5660_115_0	2	1	Preferred Generic	1	2	001010		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		4.00		12.00																															8.00							12.00				4.00					4.00			4.00				
S5660	116	0		29	10	S5660_116_0	1	5	Specialty Tier	1	2	010010		1	110000000010000100100111	31													31			31			31		31	7	31	7					280.00	25																														25							25					25				25			25			
S5660	116	0		29	10	S5660_116_0	1	4	Non-Preferred Brand	1	2	110000		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					99.00	50		50																														50							50			50				50			50			
S5660	116	0		29	10	S5660_116_0	1	2	Non-Preferred Generic	1	2	000110		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		6.00		18.00																															12.00							18.00				6.00					6.00			6.00				
S5660	116	0		29	10	S5660_116_0	1	1	Preferred Generic	1	2	001010		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		4.00		12.00																															8.00							12.00				4.00					4.00			4.00				
S5660	116	0		29	10	S5660_116_0	1	3	Preferred Brand	1	2	010001		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					42.00	25		25																														25							25			25				25			25			
S5660	117	0		29	10	S5660_117_0	2	1	Preferred Generic	1	2	001010		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		4.00		12.00																															8.00							12.00				4.00					4.00			4.00				
S5660	117	0		29	10	S5660_117_0	2	2	Non-Preferred Generic	1	2	000110		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		6.00		18.00																															12.00							18.00				6.00					6.00			6.00				
S5660	117	0		29	10	S5660_117_0	2	3	Preferred Brand	1	2	010001		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					42.00	25		25																														25							25			25				25			25			
S5660	117	0		29	10	S5660_117_0	2	4	Non-Preferred Brand	1	2	110000		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					103.00	45		45																														45							45			45				45			45			
S5660	117	0		29	10	S5660_117_0	2	5	Specialty Tier	1	2	010010		1	110000000010000100100111	31													31			31			31		31	7	31	7					298.00	25																														25							25					25				25			25			
S5660	118	0		29	10	S5660_118_0	2	4	Non-Preferred Brand	1	2	110000		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					104.00	36		36																														36							36			36				36			36			
S5660	118	0		29	10	S5660_118_0	2	3	Preferred Brand	1	2	010001		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					43.00	25		25																														25							25			25				25			25			
S5660	118	0		29	10	S5660_118_0	2	2	Non-Preferred Generic	1	2	000110		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		7.00		21.00																															14.00							21.00				7.00					7.00			7.00				
S5660	118	0		29	10	S5660_118_0	2	1	Preferred Generic	1	2	001010		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		4.00		12.00																															8.00							12.00				4.00					4.00			4.00				
S5660	118	0		29	10	S5660_118_0	2	5	Specialty Tier	1	2	010010		1	110000000010000100100111	31													31			31			31		31	7	31	7					266.00	25																														25							25					25				25			25			
S5660	119	0		29	10	S5660_119_0	1	4	Non-Preferred Brand	1	2	110000		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					102.00	50		50																														50							50			50				50			50			
S5660	119	0		29	10	S5660_119_0	1	3	Preferred Brand	1	2	010001		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					39.00	25		25																														25							25			25				25			25			
S5660	119	0		29	10	S5660_119_0	1	2	Non-Preferred Generic	1	2	000110		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		6.00		18.00																															12.00							18.00				6.00					6.00			6.00				
S5660	119	0		29	10	S5660_119_0	1	1	Preferred Generic	1	2	001010		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		4.00		12.00																															8.00							12.00				4.00					4.00			4.00				
S5660	119	0		29	10	S5660_119_0	1	5	Specialty Tier	1	2	010010		1	110000000010000100100111	31													31			31			31		31	7	31	7					271.00	25																														25							25					25				25			25			
S5660	120	0		29	10	S5660_120_0	1	1	Preferred Generic	1	2	001010		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		4.00		12.00																															8.00							12.00				4.00					4.00			4.00				
S5660	120	0		29	10	S5660_120_0	1	5	Specialty Tier	1	2	010010		1	110000000010000100100111	31													31			31			31		31	7	31	7					312.00	25																														25							25					25				25			25			
S5660	120	0		29	10	S5660_120_0	1	4	Non-Preferred Brand	1	2	110000		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					101.00	50		50																														50							50			50				50			50			
S5660	120	0		29	10	S5660_120_0	1	3	Preferred Brand	1	2	010001		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					39.00	25		25																														25							25			25				25			25			
S5660	120	0		29	10	S5660_120_0	1	2	Non-Preferred Generic	1	2	000110		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		7.00		21.00																															14.00							21.00				7.00					7.00			7.00				
S5660	121	0		29	10	S5660_121_0	2	4	Non-Preferred Brand	1	2	110000		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					103.00	48		48																														48							48			48				48			48			
S5660	121	0		29	10	S5660_121_0	2	5	Specialty Tier	1	2	010010		1	110000000010000100100111	31													31			31			31		31	7	31	7					281.00	25																														25							25					25				25			25			
S5660	121	0		29	10	S5660_121_0	2	3	Preferred Brand	1	2	010001		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					41.00	25		25																														25							25			25				25			25			
S5660	121	0		29	10	S5660_121_0	2	2	Non-Preferred Generic	1	2	000110		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		6.00		18.00																															12.00							18.00				6.00					6.00			6.00				
S5660	121	0		29	10	S5660_121_0	2	1	Preferred Generic	1	2	001010		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		4.00		12.00																															8.00							12.00				4.00					4.00			4.00				
S5660	122	0		29	10	S5660_122_0	1	4	Non-Preferred Brand	1	2	110000		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					83.00	50		50																														50							50			50				50			50			
S5660	122	0		29	10	S5660_122_0	1	5	Specialty Tier	1	2	010010		1	110000000010000100100111	31													31			31			31		31	7	31	7					292.00	25																														25							25					25				25			25			
S5660	122	0		29	10	S5660_122_0	1	1	Preferred Generic	1	2	001010		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		4.00		12.00																															8.00							12.00				4.00					4.00			4.00				
S5660	122	0		29	10	S5660_122_0	1	2	Non-Preferred Generic	1	2	000110		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		6.00		18.00																															12.00							18.00				6.00					6.00			6.00				
S5660	122	0		29	10	S5660_122_0	1	3	Preferred Brand	1	2	010001		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					39.00	25		25																														25							25			25				25			25			
S5660	123	0		29	10	S5660_123_0	1	4	Non-Preferred Brand	1	2	110000		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					102.00	50		50																														50							50			50				50			50			
S5660	123	0		29	10	S5660_123_0	1	5	Specialty Tier	1	2	010010		1	110000000010000100100111	31													31			31			31		31	7	31	7					263.00	25																														25							25					25				25			25			
S5660	123	0		29	10	S5660_123_0	1	1	Preferred Generic	1	2	001010		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		4.00		12.00																															8.00							12.00				4.00					4.00			4.00				
S5660	123	0		29	10	S5660_123_0	1	2	Non-Preferred Generic	1	2	000110		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		6.00		18.00																															12.00							18.00				6.00					6.00			6.00				
S5660	123	0		29	10	S5660_123_0	1	3	Preferred Brand	1	2	010001		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					41.00	25		25																														25							25			25				25			25			
S5660	124	0		29	10	S5660_124_0	1	1	Preferred Generic	1	2	001010		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		4.00		12.00																															8.00							12.00				4.00					4.00			4.00				
S5660	124	0		29	10	S5660_124_0	1	2	Non-Preferred Generic	1	2	000110		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		7.00		21.00																															14.00							21.00				7.00					7.00			7.00				
S5660	124	0		29	10	S5660_124_0	1	3	Preferred Brand	1	2	010001		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					38.00	25		25																														25							25			25				25			25			
S5660	124	0		29	10	S5660_124_0	1	4	Non-Preferred Brand	1	2	110000		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					80.00	50		50																														50							50			50				50			50			
S5660	124	0		29	10	S5660_124_0	1	5	Specialty Tier	1	2	010010		1	110000000010000100100111	31													31			31			31		31	7	31	7					267.00	25																														25							25					25				25			25			
S5660	125	0		29	10	S5660_125_0	2	1	Preferred Generic	1	2	001010		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		4.00		12.00																															8.00							12.00				4.00					4.00			4.00				
S5660	125	0		29	10	S5660_125_0	2	4	Non-Preferred Brand	1	2	110000		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					102.00	45		45																														45							45			45				45			45			
S5660	125	0		29	10	S5660_125_0	2	5	Specialty Tier	1	2	010010		1	110000000010000100100111	31													31			31			31		31	7	31	7					297.00	25																														25							25					25				25			25			
S5660	125	0		29	10	S5660_125_0	2	3	Preferred Brand	1	2	010001		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					42.00	25		25																														25							25			25				25			25			
S5660	125	0		29	10	S5660_125_0	2	2	Non-Preferred Generic	1	2	000110		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		6.00		18.00																															12.00							18.00				6.00					6.00			6.00				
S5660	126	0		29	10	S5660_126_0	2	5	Specialty Tier	1	2	010010		1	110000000010000100100111	31													31			31			31		31	7	31	7					306.00	25																														25							25					25				25			25			
S5660	126	0		29	10	S5660_126_0	2	4	Non-Preferred Brand	1	2	110000		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					104.00	45		45																														45							45			45				45			45			
S5660	126	0		29	10	S5660_126_0	2	3	Preferred Brand	1	2	010001		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					42.00	25		25																														25							25			25				25			25			
S5660	126	0		29	10	S5660_126_0	2	2	Non-Preferred Generic	1	2	000110		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		6.00		18.00																															12.00							18.00				6.00					6.00			6.00				
S5660	126	0		29	10	S5660_126_0	2	1	Preferred Generic	1	2	001010		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		4.00		12.00																															8.00							12.00				4.00					4.00			4.00				
S5660	127	0		29	10	S5660_127_0	1	4	Non-Preferred Brand	1	2	110000		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					92.00	50		50																														50							50			50				50			50			
S5660	127	0		29	10	S5660_127_0	1	5	Specialty Tier	1	2	010010		1	110000000010000100100111	31													31			31			31		31	7	31	7					263.00	25																														25							25					25				25			25			
S5660	127	0		29	10	S5660_127_0	1	3	Preferred Brand	1	2	010001		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					38.00	25		25																														25							25			25				25			25			
S5660	127	0		29	10	S5660_127_0	1	2	Non-Preferred Generic	1	2	000110		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		6.00		18.00																															12.00							18.00				6.00					6.00			6.00				
S5660	127	0		29	10	S5660_127_0	1	1	Preferred Generic	1	2	001010		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		4.00		12.00																															8.00							12.00				4.00					4.00			4.00				
S5660	128	0		29	10	S5660_128_0	1	5	Specialty Tier	1	2	010010		1	110000000010000100100111	31													31			31			31		31	7	31	7					275.00	25																														25							25					25				25			25			
S5660	128	0		29	10	S5660_128_0	1	4	Non-Preferred Brand	1	2	110000		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					72.00	50		50																														50							50			50				50			50			
S5660	128	0		29	10	S5660_128_0	1	3	Preferred Brand	1	2	010001		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					41.00	25		25																														25							25			25				25			25			
S5660	128	0		29	10	S5660_128_0	1	2	Non-Preferred Generic	1	2	000110		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		7.00		21.00																															14.00							21.00				7.00					7.00			7.00				
S5660	128	0		29	10	S5660_128_0	1	1	Preferred Generic	1	2	001010		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		4.00		12.00																															8.00							12.00				4.00					4.00			4.00				
S5660	129	0		29	10	S5660_129_0	1	1	Preferred Generic	1	2	001010		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		4.00		12.00																															8.00							12.00				4.00					4.00			4.00				
S5660	129	0		29	10	S5660_129_0	1	2	Non-Preferred Generic	1	2	000110		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		7.00		21.00																															14.00							21.00				7.00					7.00			7.00				
S5660	129	0		29	10	S5660_129_0	1	3	Preferred Brand	1	2	010001		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					40.00	25		25																														25							25			25				25			25			
S5660	129	0		29	10	S5660_129_0	1	4	Non-Preferred Brand	1	2	110000		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					84.00	50		50																														50							50			50				50			50			
S5660	129	0		29	10	S5660_129_0	1	5	Specialty Tier	1	2	010010		1	110000000010000100100111	31													31			31			31		31	7	31	7					234.00	25																														25							25					25				25			25			
S5660	130	0		29	10	S5660_130_0	1	5	Specialty Tier	1	2	010010		1	110000000010000100100111	31													31			31			31		31	7	31	7					308.00	25																														25							25					25				25			25			
S5660	130	0		29	10	S5660_130_0	1	4	Non-Preferred Brand	1	2	110000		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					70.00	50		50																														50							50			50				50			50			
S5660	130	0		29	10	S5660_130_0	1	3	Preferred Brand	1	2	010001		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					38.00	25		25																														25							25			25				25			25			
S5660	130	0		29	10	S5660_130_0	1	2	Non-Preferred Generic	1	2	000110		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		7.00		21.00																															14.00							21.00				7.00					7.00			7.00				
S5660	130	0		29	10	S5660_130_0	1	1	Preferred Generic	1	2	001010		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		4.00		12.00																															8.00							12.00				4.00					4.00			4.00				
S5660	131	0		29	10	S5660_131_0	2	5	Specialty Tier	1	2	010010		1	110000000010000100100111	31													31			31			31		31	7	31	7					229.00	25																														25							25					25				25			25			
S5660	131	0		29	10	S5660_131_0	2	4	Non-Preferred Brand	1	2	110000		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					104.00	45		45																														45							45			45				45			45			
S5660	131	0		29	10	S5660_131_0	2	3	Preferred Brand	1	2	010001		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					40.00	25		25																														25							25			25				25			25			
S5660	131	0		29	10	S5660_131_0	2	2	Non-Preferred Generic	1	2	000110		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		8.00		24.00																															16.00							24.00				8.00					8.00			8.00				
S5660	131	0		29	10	S5660_131_0	2	1	Preferred Generic	1	2	001010		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		4.00		12.00																															8.00							12.00				4.00					4.00			4.00				
S5660	132	0		29	10	S5660_132_0	1	1	Preferred Generic	1	2	001010		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		4.00		12.00																															8.00							12.00				4.00					4.00			4.00				
S5660	132	0		29	10	S5660_132_0	1	2	Non-Preferred Generic	1	2	000110		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		7.00		21.00																															14.00							21.00				7.00					7.00			7.00				
S5660	132	0		29	10	S5660_132_0	1	3	Preferred Brand	1	2	010001		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					42.00	25		25																														25							25			25				25			25			
S5660	132	0		29	10	S5660_132_0	1	4	Non-Preferred Brand	1	2	110000		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					100.00	50		50																														50							50			50				50			50			
S5660	132	0		29	10	S5660_132_0	1	5	Specialty Tier	1	2	010010		1	110000000010000100100111	31													31			31			31		31	7	31	7					288.00	25																														25							25					25				25			25			
S5660	133	0		29	10	S5660_133_0	2	1	Preferred Generic	1	2	001010		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		4.00		12.00																															8.00							12.00				4.00					4.00			4.00				
S5660	133	0		29	10	S5660_133_0	2	2	Non-Preferred Generic	1	2	000110		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		7.00		21.00																															14.00							21.00				7.00					7.00			7.00				
S5660	133	0		29	10	S5660_133_0	2	3	Preferred Brand	1	2	010001		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					47.00	25		25																														25							25			25				25			25			
S5660	133	0		29	10	S5660_133_0	2	4	Non-Preferred Brand	1	2	110000		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					103.00	39		39																														39							39			39				39			39			
S5660	133	0		29	10	S5660_133_0	2	5	Specialty Tier	1	2	010010		1	110000000010000100100111	31													31			31			31		31	7	31	7					292.00	25																														25							25					25				25			25			
S5660	134	0		29	10	S5660_134_0	1	4	Non-Preferred Brand	1	2	110000		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					86.00	50		50																														50							50			50				50			50			
S5660	134	0		29	10	S5660_134_0	1	3	Preferred Brand	1	2	010001		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					37.00	25		25																														25							25			25				25			25			
S5660	134	0		29	10	S5660_134_0	1	5	Specialty Tier	1	2	010010		1	110000000010000100100111	31													31			31			31		31	7	31	7					309.00	25																														25							25					25				25			25			
S5660	134	0		29	10	S5660_134_0	1	2	Non-Preferred Generic	1	2	000110		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		7.00		21.00																															14.00							21.00				7.00					7.00			7.00				
S5660	134	0		29	10	S5660_134_0	1	1	Preferred Generic	1	2	001010		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		4.00		12.00																															8.00							12.00				4.00					4.00			4.00				
S5660	135	0		29	10	S5660_135_0	2	2	Non-Preferred Generic	1	2	000110		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		8.00		24.00																															16.00							24.00				8.00					8.00			8.00				
S5660	135	0		29	10	S5660_135_0	2	1	Preferred Generic	1	2	001010		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		4.00		12.00																															8.00							12.00				4.00					4.00			4.00				
S5660	135	0		29	10	S5660_135_0	2	3	Preferred Brand	1	2	010001		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					59.00	25		25																														25							25			25				25			25			
S5660	135	0		29	10	S5660_135_0	2	5	Specialty Tier	1	2	010010		1	110000000010000100100111	31													31			31			31		31	7	31	7					225.00	25																														25							25					25				25			25			
S5660	135	0		29	10	S5660_135_0	2	4	Non-Preferred Brand	1	2	110000		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					102.00	27		27																														27							27			27				27			27			
S5660	136	0		29	10	S5660_136_0	2	1	Preferred Generic	1	2	001010		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		4.00		12.00																															8.00							12.00				4.00					4.00			4.00				
S5660	136	0		29	10	S5660_136_0	2	2	Non-Preferred Generic	1	2	000110		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		6.00		18.00																															12.00							18.00				6.00					6.00			6.00				
S5660	136	0		29	10	S5660_136_0	2	3	Preferred Brand	1	2	010001		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					46.00	25		25																														25							25			25				25			25			
S5660	136	0		29	10	S5660_136_0	2	4	Non-Preferred Brand	1	2	110000		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					104.00	45		45																														45							45			45				45			45			
S5660	136	0		29	10	S5660_136_0	2	5	Specialty Tier	1	2	010010		1	110000000010000100100111	31													31			31			31		31	7	31	7					435.00	25																														25							25					25				25			25			
S5660	137	0		29	10	S5660_137_0	1	2	Non-Preferred Generic	1	2	000110		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		7.00		21.00																															14.00							21.00				7.00					7.00			7.00				
S5660	137	0		29	10	S5660_137_0	1	1	Preferred Generic	1	2	001010		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		4.00		12.00																															8.00							12.00				4.00					4.00			4.00				
S5660	137	0		29	10	S5660_137_0	1	3	Preferred Brand	1	2	010001		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					48.00	25		25																														25							25			25				25			25			
S5660	137	0		29	10	S5660_137_0	1	5	Specialty Tier	1	2	010010		1	110000000010000100100111	31													31			31			31		31	7	31	7					347.00	25																														25							25					25				25			25			
S5660	137	0		29	10	S5660_137_0	1	4	Non-Preferred Brand	1	2	110000		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					105.00	50		50																														50							50			50				50			50			
S5660	172	0		29	10	S5660_172_0	2	1	Generic	1	4	010010	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		8.00		24.00																															0.00							24.00				8.00					8.00			8.00				
S5660	172	0		29	10	S5660_172_0	2	4	Specialty Tier	1	4	010010	1	1	110000000010000100100111	31													31			31			31		31	7	31	7					381.00	28																														28							28					28				28			28			
S5660	172	0		29	10	S5660_172_0	2	1	Generic	3	4	010010	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		8.00		24.00																															0.00							24.00				8.00					8.00			8.00		1		
S5660	172	0		29	10	S5660_172_0	2	2	Preferred Brand	1	4	010001	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		45.00		135.00																															113.00							135.00				45.00					45.00			45.00				
S5660	172	0		29	10	S5660_172_0	2	3	Non-Preferred Brand	1	4	110000	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		95.00		285.00																															238.00							285.00				95.00					95.00			95.00				
S5660	176	0		29	10	S5660_176_0	1	4	Specialty Tier	1	4	010010	1	1	110000000010000100100111	31													31			31			31		31	7	31	7					129.00	28																														28							28					28				28			28			
S5660	176	0		29	10	S5660_176_0	1	1	Generic	3	4	010010	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		8.00		24.00																															0.00							24.00				8.00					8.00			8.00		1		
S5660	176	0		29	10	S5660_176_0	1	3	Non-Preferred Brand	1	4	110000	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		95.00		285.00																															238.00							285.00				95.00					95.00			95.00				
S5660	176	0		29	10	S5660_176_0	1	2	Preferred Brand	1	4	010001	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		45.00		135.00																															113.00							135.00				45.00					45.00			45.00				
S5660	176	0		29	10	S5660_176_0	1	1	Generic	1	4	010010	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		8.00		24.00																															0.00							24.00				8.00					8.00			8.00				
S5660	180	0		29	10	S5660_180_0	1	1	Generic	1	4	010010	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		8.00		24.00																															0.00							24.00				8.00					8.00			8.00				
S5660	180	0		29	10	S5660_180_0	1	2	Preferred Brand	1	4	010001	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		45.00		135.00																															113.00							135.00				45.00					45.00			45.00				
S5660	180	0		29	10	S5660_180_0	1	3	Non-Preferred Brand	1	4	110000	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		95.00		285.00																															238.00							285.00				95.00					95.00			95.00				
S5660	180	0		29	10	S5660_180_0	1	4	Specialty Tier	1	4	010010	1	1	110000000010000100100111	31													31			31			31		31	7	31	7					300.00	28																														28							28					28				28			28			
S5660	180	0		29	10	S5660_180_0	1	1	Generic	3	4	010010	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		8.00		24.00																															0.00							24.00				8.00					8.00			8.00		1		
S5660	181	0		29	10	S5660_181_0	1	1	Generic	3	4	010010	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		8.00		24.00																															0.00							24.00				8.00					8.00			8.00		1		
S5660	181	0		29	10	S5660_181_0	1	4	Specialty Tier	1	4	010010	1	1	110000000010000100100111	31													31			31			31		31	7	31	7					266.00	28																														28							28					28				28			28			
S5660	181	0		29	10	S5660_181_0	1	3	Non-Preferred Brand	1	4	110000	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		95.00		285.00																															238.00							285.00				95.00					95.00			95.00				
S5660	181	0		29	10	S5660_181_0	1	2	Preferred Brand	1	4	010001	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		45.00		135.00																															113.00							135.00				45.00					45.00			45.00				
S5660	181	0		29	10	S5660_181_0	1	1	Generic	1	4	010010	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		8.00		24.00																															0.00							24.00				8.00					8.00			8.00				
S5660	182	0		29	10	S5660_182_0	1	1	Generic	3	4	010010	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		8.00		24.00																															0.00							24.00				8.00					8.00			8.00		1		
S5660	182	0		29	10	S5660_182_0	1	4	Specialty Tier	1	4	010010	1	1	110000000010000100100111	31													31			31			31		31	7	31	7					291.00	28																														28							28					28				28			28			
S5660	182	0		29	10	S5660_182_0	1	3	Non-Preferred Brand	1	4	110000	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		95.00		285.00																															238.00							285.00				95.00					95.00			95.00				
S5660	182	0		29	10	S5660_182_0	1	2	Preferred Brand	1	4	010001	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		45.00		135.00																															113.00							135.00				45.00					45.00			45.00				
S5660	182	0		29	10	S5660_182_0	1	1	Generic	1	4	010010	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		8.00		24.00																															0.00							24.00				8.00					8.00			8.00				
S5660	183	0		29	10	S5660_183_0	1	1	Generic	1	4	010010	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		8.00		24.00																															0.00							24.00				8.00					8.00			8.00				
S5660	183	0		29	10	S5660_183_0	1	4	Specialty Tier	1	4	010010	1	1	110000000010000100100111	31													31			31			31		31	7	31	7					325.00	28																														28							28					28				28			28			
S5660	183	0		29	10	S5660_183_0	1	3	Non-Preferred Brand	1	4	110000	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		95.00		285.00																															238.00							285.00				95.00					95.00			95.00				
S5660	183	0		29	10	S5660_183_0	1	2	Preferred Brand	1	4	010001	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		45.00		135.00																															113.00							135.00				45.00					45.00			45.00				
S5660	183	0		29	10	S5660_183_0	1	1	Generic	3	4	010010	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		8.00		24.00																															0.00							24.00				8.00					8.00			8.00		1		
S5660	184	0		29	10	S5660_184_0	1	2	Preferred Brand	1	4	010001	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		45.00		135.00																															113.00							135.00				45.00					45.00			45.00				
S5660	184	0		29	10	S5660_184_0	1	3	Non-Preferred Brand	1	4	110000	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		95.00		285.00																															238.00							285.00				95.00					95.00			95.00				
S5660	184	0		29	10	S5660_184_0	1	1	Generic	3	4	010010	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		8.00		24.00																															0.00							24.00				8.00					8.00			8.00		1		
S5660	184	0		29	10	S5660_184_0	1	4	Specialty Tier	1	4	010010	1	1	110000000010000100100111	31													31			31			31		31	7	31	7					276.00	28																														28							28					28				28			28			
S5660	184	0		29	10	S5660_184_0	1	1	Generic	1	4	010010	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		8.00		24.00																															0.00							24.00				8.00					8.00			8.00				
S5660	185	0		29	10	S5660_185_0	1	1	Generic	1	4	010010	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		8.00		24.00																															0.00							24.00				8.00					8.00			8.00				
S5660	185	0		29	10	S5660_185_0	1	2	Preferred Brand	1	4	010001	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		45.00		135.00																															113.00							135.00				45.00					45.00			45.00				
S5660	185	0		29	10	S5660_185_0	1	3	Non-Preferred Brand	1	4	110000	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		95.00		285.00																															238.00							285.00				95.00					95.00			95.00				
S5660	185	0		29	10	S5660_185_0	1	4	Specialty Tier	1	4	010010	1	1	110000000010000100100111	31													31			31			31		31	7	31	7					294.00	28																														28							28					28				28			28			
S5660	185	0		29	10	S5660_185_0	1	1	Generic	3	4	010010	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		8.00		24.00																															0.00							24.00				8.00					8.00			8.00		1		
S5660	186	0		29	10	S5660_186_0	1	4	Specialty Tier	1	4	010010	1	1	110000000010000100100111	31													31			31			31		31	7	31	7					290.00	28																														28							28					28				28			28			
S5660	186	0		29	10	S5660_186_0	1	3	Non-Preferred Brand	1	4	110000	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		95.00		285.00																															238.00							285.00				95.00					95.00			95.00				
S5660	186	0		29	10	S5660_186_0	1	2	Preferred Brand	1	4	010001	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		45.00		135.00																															113.00							135.00				45.00					45.00			45.00				
S5660	186	0		29	10	S5660_186_0	1	1	Generic	1	4	010010	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		8.00		24.00																															0.00							24.00				8.00					8.00			8.00				
S5660	186	0		29	10	S5660_186_0	1	1	Generic	3	4	010010	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		8.00		24.00																															0.00							24.00				8.00					8.00			8.00		1		
S5660	187	0		29	10	S5660_187_0	1	4	Specialty Tier	1	4	010010	1	1	110000000010000100100111	31													31			31			31		31	7	31	7					208.00	28																														28							28					28				28			28			
S5660	187	0		29	10	S5660_187_0	1	3	Non-Preferred Brand	1	4	110000	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		95.00		285.00																															238.00							285.00				95.00					95.00			95.00				
S5660	187	0		29	10	S5660_187_0	1	2	Preferred Brand	1	4	010001	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		45.00		135.00																															113.00							135.00				45.00					45.00			45.00				
S5660	187	0		29	10	S5660_187_0	1	1	Generic	1	4	010010	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		8.00		24.00																															0.00							24.00				8.00					8.00			8.00				
S5660	187	0		29	10	S5660_187_0	1	1	Generic	3	4	010010	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		8.00		24.00																															0.00							24.00				8.00					8.00			8.00		1		
S5660	190	0		29	10	S5660_190_0	1	1	Generic	1	4	010010	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		8.00		24.00																															0.00							24.00				8.00					8.00			8.00				
S5660	190	0		29	10	S5660_190_0	1	2	Preferred Brand	1	4	010001	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		45.00		135.00																															113.00							135.00				45.00					45.00			45.00				
S5660	190	0		29	10	S5660_190_0	1	3	Non-Preferred Brand	1	4	110000	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		95.00		285.00																															238.00							285.00				95.00					95.00			95.00				
S5660	190	0		29	10	S5660_190_0	1	4	Specialty Tier	1	4	010010	1	1	110000000010000100100111	31													31			31			31		31	7	31	7					269.00	28																														28							28					28				28			28			
S5660	190	0		29	10	S5660_190_0	1	1	Generic	3	4	010010	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		8.00		24.00																															0.00							24.00				8.00					8.00			8.00		1		
S5660	192	0		29	10	S5660_192_0	1	4	Specialty Tier	1	4	010010	1	1	110000000010000100100111	31													31			31			31		31	7	31	7					299.00	28																														28							28					28				28			28			
S5660	192	0		29	10	S5660_192_0	1	3	Non-Preferred Brand	1	4	110000	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		95.00		285.00																															238.00							285.00				95.00					95.00			95.00				
S5660	192	0		29	10	S5660_192_0	1	2	Preferred Brand	1	4	010001	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		45.00		135.00																															113.00							135.00				45.00					45.00			45.00				
S5660	192	0		29	10	S5660_192_0	1	1	Generic	1	4	010010	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		8.00		24.00																															0.00							24.00				8.00					8.00			8.00				
S5660	192	0		29	10	S5660_192_0	1	1	Generic	3	4	010010	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		8.00		24.00																															0.00							24.00				8.00					8.00			8.00		1		
S5660	194	0		29	10	S5660_194_0	1	2	Preferred Brand	1	4	010001	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		45.00		135.00																															113.00							135.00				45.00					45.00			45.00				
S5660	194	0		29	10	S5660_194_0	1	1	Generic	1	4	010010	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		8.00		24.00																															0.00							24.00				8.00					8.00			8.00				
S5660	194	0		29	10	S5660_194_0	1	3	Non-Preferred Brand	1	4	110000	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		95.00		285.00																															238.00							285.00				95.00					95.00			95.00				
S5660	194	0		29	10	S5660_194_0	1	4	Specialty Tier	1	4	010010	1	1	110000000010000100100111	31													31			31			31		31	7	31	7					218.00	28																														28							28					28				28			28			
S5660	194	0		29	10	S5660_194_0	1	1	Generic	3	4	010010	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		8.00		24.00																															0.00							24.00				8.00					8.00			8.00		1		
S5660	195	0		29	10	S5660_195_0	1	2	Preferred Brand	1	4	010001	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		45.00		135.00																															113.00							135.00				45.00					45.00			45.00				
S5660	195	0		29	10	S5660_195_0	1	1	Generic	1	4	010010	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		8.00		24.00																															0.00							24.00				8.00					8.00			8.00				
S5660	195	0		29	10	S5660_195_0	1	3	Non-Preferred Brand	1	4	110000	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		95.00		285.00																															238.00							285.00				95.00					95.00			95.00				
S5660	195	0		29	10	S5660_195_0	1	1	Generic	3	4	010010	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		8.00		24.00																															0.00							24.00				8.00					8.00			8.00		1		
S5660	195	0		29	10	S5660_195_0	1	4	Specialty Tier	1	4	010010	1	1	110000000010000100100111	31													31			31			31		31	7	31	7					326.00	28																														28							28					28				28			28			
S5660	196	0		29	10	S5660_196_0	1	1	Generic	1	4	010010	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		8.00		24.00																															0.00							24.00				8.00					8.00			8.00				
S5660	196	0		29	10	S5660_196_0	1	2	Preferred Brand	1	4	010001	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		45.00		135.00																															113.00							135.00				45.00					45.00			45.00				
S5660	196	0		29	10	S5660_196_0	1	4	Specialty Tier	1	4	010010	1	1	110000000010000100100111	31													31			31			31		31	7	31	7					309.00	28																														28							28					28				28			28			
S5660	196	0		29	10	S5660_196_0	1	3	Non-Preferred Brand	1	4	110000	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		95.00		285.00																															238.00							285.00				95.00					95.00			95.00				
S5660	196	0		29	10	S5660_196_0	1	1	Generic	3	4	010010	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		8.00		24.00																															0.00							24.00				8.00					8.00			8.00		1		
S5660	197	0		29	10	S5660_197_0	1	1	Generic	3	4	010010	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		8.00		24.00																															0.00							24.00				8.00					8.00			8.00		1		
S5660	197	0		29	10	S5660_197_0	1	1	Generic	1	4	010010	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		8.00		24.00																															0.00							24.00				8.00					8.00			8.00				
S5660	197	0		29	10	S5660_197_0	1	2	Preferred Brand	1	4	010001	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		45.00		135.00																															113.00							135.00				45.00					45.00			45.00				
S5660	197	0		29	10	S5660_197_0	1	3	Non-Preferred Brand	1	4	110000	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		95.00		285.00																															238.00							285.00				95.00					95.00			95.00				
S5660	197	0		29	10	S5660_197_0	1	4	Specialty Tier	1	4	010010	1	1	110000000010000100100111	31													31			31			31		31	7	31	7					285.00	28																														28							28					28				28			28			
S5660	198	0		29	10	S5660_198_0	1	1	Generic	1	4	010010	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		8.00		24.00																															0.00							24.00				8.00					8.00			8.00				
S5660	198	0		29	10	S5660_198_0	1	2	Preferred Brand	1	4	010001	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		45.00		135.00																															113.00							135.00				45.00					45.00			45.00				
S5660	198	0		29	10	S5660_198_0	1	3	Non-Preferred Brand	1	4	110000	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		95.00		285.00																															238.00							285.00				95.00					95.00			95.00				
S5660	198	0		29	10	S5660_198_0	1	4	Specialty Tier	1	4	010010	1	1	110000000010000100100111	31													31			31			31		31	7	31	7					363.00	28																														28							28					28				28			28			
S5660	198	0		29	10	S5660_198_0	1	1	Generic	3	4	010010	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		8.00		24.00																															0.00							24.00				8.00					8.00			8.00		1		
S5660	199	0		29	10	S5660_199_0	1	1	Generic	1	4	010010	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		8.00		24.00																															0.00							24.00				8.00					8.00			8.00				
S5660	199	0		29	10	S5660_199_0	1	2	Preferred Brand	1	4	010001	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		45.00		135.00																															113.00							135.00				45.00					45.00			45.00				
S5660	199	0		29	10	S5660_199_0	1	3	Non-Preferred Brand	1	4	110000	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		95.00		285.00																															238.00							285.00				95.00					95.00			95.00				
S5660	199	0		29	10	S5660_199_0	1	4	Specialty Tier	1	4	010010	1	1	110000000010000100100111	31													31			31			31		31	7	31	7					362.00	28																														28							28					28				28			28			
S5660	199	0		29	10	S5660_199_0	1	1	Generic	3	4	010010	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		8.00		24.00																															0.00							24.00				8.00					8.00			8.00		1		
S5660	202	0		29	10	S5660_202_0	1	3	Non-Preferred Brand	1	4	110000	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		95.00		285.00																															238.00							285.00				95.00					95.00			95.00				
S5660	202	0		29	10	S5660_202_0	1	2	Preferred Brand	1	4	010001	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		45.00		135.00																															113.00							135.00				45.00					45.00			45.00				
S5660	202	0		29	10	S5660_202_0	1	1	Generic	1	4	010010	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		8.00		24.00																															0.00							24.00				8.00					8.00			8.00				
S5660	202	0		29	10	S5660_202_0	1	1	Generic	3	4	010010	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		8.00		24.00																															0.00							24.00				8.00					8.00			8.00		1		
S5660	202	0		29	10	S5660_202_0	1	4	Specialty Tier	1	4	010010	1	1	110000000010000100100111	31													31			31			31		31	7	31	7					291.00	28																														28							28					28				28			28			
S5660	203	0		29	10	S5660_203_0	1	1	Generic	1	4	010010	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		8.00		24.00																															0.00							24.00				8.00					8.00			8.00				
S5660	203	0		29	10	S5660_203_0	1	3	Non-Preferred Brand	1	4	110000	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		95.00		285.00																															238.00							285.00				95.00					95.00			95.00				
S5660	203	0		29	10	S5660_203_0	1	4	Specialty Tier	1	4	010010	1	1	110000000010000100100111	31													31			31			31		31	7	31	7					427.00	28																														28							28					28				28			28			
S5660	203	0		29	10	S5660_203_0	1	1	Generic	3	4	010010	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		8.00		24.00																															0.00							24.00				8.00					8.00			8.00		1		
S5660	203	0		29	10	S5660_203_0	1	2	Preferred Brand	1	4	010001	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		45.00		135.00																															113.00							135.00				45.00					45.00			45.00				
S5660	204	0		29	10	S5660_204_0	1	1	Generic	3	4	010010	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		8.00		24.00																															0.00							24.00				8.00					8.00			8.00		1		
S5660	204	0		29	10	S5660_204_0	1	3	Non-Preferred Brand	1	4	110000	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		95.00		285.00																															238.00							285.00				95.00					95.00			95.00				
S5660	204	0		29	10	S5660_204_0	1	4	Specialty Tier	1	4	010010	1	1	110000000010000100100111	31													31			31			31		31	7	31	7					168.00	28																														28							28					28				28			28			
S5660	204	0		29	10	S5660_204_0	1	2	Preferred Brand	1	4	010001	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		45.00		135.00																															113.00							135.00				45.00					45.00			45.00				
S5660	204	0		29	10	S5660_204_0	1	1	Generic	1	4	010010	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		8.00		24.00																															0.00							24.00				8.00					8.00			8.00				
S5660	205	0		29	10	S5660_205_0	1	1	Generic	1	4	010010	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		8.00		24.00																															0.00							24.00				8.00					8.00			8.00				
S5660	205	0		29	10	S5660_205_0	1	2	Preferred Brand	1	4	010001	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		45.00		135.00																															113.00							135.00				45.00					45.00			45.00				
S5660	205	0		29	10	S5660_205_0	1	3	Non-Preferred Brand	1	4	110000	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		95.00		285.00																															238.00							285.00				95.00					95.00			95.00				
S5660	205	0		29	10	S5660_205_0	1	4	Specialty Tier	1	4	010010	1	1	110000000010000100100111	31													31			31			31		31	7	31	7					285.00	28																														28							28					28				28			28			
S5660	205	0		29	10	S5660_205_0	1	1	Generic	3	4	010010	1	2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		8.00		24.00																															0.00							24.00				8.00					8.00			8.00		1		
S5670	030	0		29	10	S5670_030_0	2	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					20.00		60.00																						20.00		50.00																		20.00					20.00							
S5670	030	0		29	10	S5670_030_0	2	1	Preferred Generic	1	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00							
S5670	030	0		29	10	S5670_030_0	2	4	Non-Preferred Brand	3	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					228.88	43		43																					43		43																	43				43			43	2	1	
S5670	030	0		29	10	S5670_030_0	2	3	Preferred Brand	3	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					195.00	25		25																					25		25																	25							25	2		1
S5670	030	0		29	10	S5670_030_0	2	1	Preferred Generic	3	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					3.00		9.00																						3.00		7.50																		3.00					3.00					1		
S5670	030	0		29	10	S5670_030_0	2	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					230.37	33																																										33				33			33			
S5670	030	0		29	10	S5670_030_0	2	4	Non-Preferred Brand	1	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					69.39	43		43																					43		43																	43				43			43			
S5670	030	0		29	10	S5670_030_0	2	3	Preferred Brand	1	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					39.32	25		25																					25		25																	25							25			
S5670	036	0		29	10	S5670_036_0	2	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					20.00		60.00																						20.00		50.00																		20.00					20.00							
S5670	036	0		29	10	S5670_036_0	2	1	Preferred Generic	1	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00							
S5670	036	0		29	10	S5670_036_0	2	4	Non-Preferred Brand	3	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					188.40	43		43																					43		43																	43				43			43	2	1	
S5670	036	0		29	10	S5670_036_0	2	3	Preferred Brand	3	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					203.93	25		25																					25		25																	25							25	2		1
S5670	036	0		29	10	S5670_036_0	2	1	Preferred Generic	3	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					3.00		9.00																						3.00		7.50																		3.00					3.00					1		
S5670	036	0		29	10	S5670_036_0	2	3	Preferred Brand	1	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					41.51	25		25																					25		25																	25							25			
S5670	036	0		29	10	S5670_036_0	2	4	Non-Preferred Brand	1	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					59.60	43		43																					43		43																	43				43			43			
S5670	036	0		29	10	S5670_036_0	2	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					348.26	33																																										33				33			33			
S5670	042	0		29	10	S5670_042_0	2	1	Preferred Generic	1	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00							
S5670	042	0		29	10	S5670_042_0	2	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					20.00		60.00																						20.00		50.00																		20.00					20.00							
S5670	042	0		29	10	S5670_042_0	2	3	Preferred Brand	1	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					40.52	25		25																					25		25																	25							25			
S5670	042	0		29	10	S5670_042_0	2	4	Non-Preferred Brand	1	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					54.01	41		41																					41		41																	41				41			41			
S5670	042	0		29	10	S5670_042_0	2	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					437.99	33																																										33				33			33			
S5670	042	0		29	10	S5670_042_0	2	1	Preferred Generic	3	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					3.00		9.00																						3.00		7.50																		3.00					3.00					1		
S5670	042	0		29	10	S5670_042_0	2	3	Preferred Brand	3	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					197.51	25		25																					25		25																	25							25	2		1
S5670	042	0		29	10	S5670_042_0	2	4	Non-Preferred Brand	3	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					180.48	41		41																					41		41																	41				41			41	2	1	
S5670	048	0		29	10	S5670_048_0	2	3	Preferred Brand	1	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					42.98	25		25																					25		25																	25							25			
S5670	048	0		29	10	S5670_048_0	2	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					20.00		60.00																						20.00		50.00																		20.00					20.00							
S5670	048	0		29	10	S5670_048_0	2	1	Preferred Generic	1	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00							
S5670	048	0		29	10	S5670_048_0	2	4	Non-Preferred Brand	1	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					56.27	43		43																					43		43																	43				43			43			
S5670	048	0		29	10	S5670_048_0	2	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					335.74	33																																										33				33			33			
S5670	048	0		29	10	S5670_048_0	2	1	Preferred Generic	3	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					3.00		9.00																						3.00		7.50																		3.00					3.00					1		
S5670	048	0		29	10	S5670_048_0	2	3	Preferred Brand	3	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					222.36	25		25																					25		25																	25							25	2		1
S5670	048	0		29	10	S5670_048_0	2	4	Non-Preferred Brand	3	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					184.91	43		43																					43		43																	43				43			43	2	1	
S5670	054	0		29	10	S5670_054_0	2	3	Preferred Brand	1	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					38.84	25		25																					25		25																	25							25			
S5670	054	0		29	10	S5670_054_0	2	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					20.00		60.00																						20.00		50.00																		20.00					20.00							
S5670	054	0		29	10	S5670_054_0	2	1	Preferred Generic	1	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00							
S5670	054	0		29	10	S5670_054_0	2	4	Non-Preferred Brand	1	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					59.85	43		43																					43		43																	43				43			43			
S5670	054	0		29	10	S5670_054_0	2	4	Non-Preferred Brand	3	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					191.15	43		43																					43		43																	43				43			43	2	1	
S5670	054	0		29	10	S5670_054_0	2	3	Preferred Brand	3	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					195.85	25		25																					25		25																	25							25	2		1
S5670	054	0		29	10	S5670_054_0	2	1	Preferred Generic	3	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					3.00		9.00																						3.00		7.50																		3.00					3.00					1		
S5670	054	0		29	10	S5670_054_0	2	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					491.32	33																																										33				33			33			
S5670	060	0		29	10	S5670_060_0	2	1	Preferred Generic	1	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00							
S5670	060	0		29	10	S5670_060_0	2	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					20.00		60.00																						20.00		50.00																		20.00					20.00							
S5670	060	0		29	10	S5670_060_0	2	3	Preferred Brand	1	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					41.72	25		25																					25		25																	25							25			
S5670	060	0		29	10	S5670_060_0	2	3	Preferred Brand	3	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					199.33	25		25																					25		25																	25							25	2		1
S5670	060	0		29	10	S5670_060_0	2	1	Preferred Generic	3	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					3.00		9.00																						3.00		7.50																		3.00					3.00					1		
S5670	060	0		29	10	S5670_060_0	2	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					309.92	33																																										33				33			33			
S5670	060	0		29	10	S5670_060_0	2	4	Non-Preferred Brand	1	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					55.45	44		44																					44		44																	44				44			44			
S5670	060	0		29	10	S5670_060_0	2	4	Non-Preferred Brand	3	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					168.34	44		44																					44		44																	44				44			44	2	1	
S5670	066	0		29	10	S5670_066_0	2	1	Preferred Generic	1	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00							
S5670	066	0		29	10	S5670_066_0	2	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					20.00		60.00																						20.00		50.00																		20.00					20.00							
S5670	066	0		29	10	S5670_066_0	2	3	Preferred Brand	1	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					39.45	25		25																					25		25																	25							25			
S5670	066	0		29	10	S5670_066_0	2	4	Non-Preferred Brand	1	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					56.21	44		44																					44		44																	44				44			44			
S5670	066	0		29	10	S5670_066_0	2	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					536.70	33																																										33				33			33			
S5670	066	0		29	10	S5670_066_0	2	1	Preferred Generic	3	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					3.00		9.00																						3.00		7.50																		3.00					3.00					1		
S5670	066	0		29	10	S5670_066_0	2	3	Preferred Brand	3	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					199.31	25		25																					25		25																	25							25	2		1
S5670	066	0		29	10	S5670_066_0	2	4	Non-Preferred Brand	3	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					177.77	44		44																					44		44																	44				44			44	2	1	
S5670	072	0		29	10	S5670_072_0	2	4	Non-Preferred Brand	3	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					206.90	41		41																					41		41																	41				41			41	2	1	
S5670	072	0		29	10	S5670_072_0	2	4	Non-Preferred Brand	1	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					57.90	41		41																					41		41																	41				41			41			
S5670	072	0		29	10	S5670_072_0	2	1	Preferred Generic	3	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					3.00		9.00																						3.00		7.50																		3.00					3.00					1		
S5670	072	0		29	10	S5670_072_0	2	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					396.45	33																																										33				33			33			
S5670	072	0		29	10	S5670_072_0	2	3	Preferred Brand	3	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					199.76	25		25																					25		25																	25							25	2		1
S5670	072	0		29	10	S5670_072_0	2	3	Preferred Brand	1	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					38.67	25		25																					25		25																	25							25			
S5670	072	0		29	10	S5670_072_0	2	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					20.00		60.00																						20.00		50.00																		20.00					20.00							
S5670	072	0		29	10	S5670_072_0	2	1	Preferred Generic	1	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00							
S5670	078	0		29	10	S5670_078_0	2	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					409.36	33																																										33				33			33			
S5670	078	0		29	10	S5670_078_0	2	1	Preferred Generic	1	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00							
S5670	078	0		29	10	S5670_078_0	2	3	Preferred Brand	3	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					199.08	25		25																					25		25																	25							25	2		1
S5670	078	0		29	10	S5670_078_0	2	4	Non-Preferred Brand	3	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					182.90	43		43																					43		43																	43				43			43	2	1	
S5670	078	0		29	10	S5670_078_0	2	1	Preferred Generic	3	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					3.00		9.00																						3.00		7.50																		3.00					3.00					1		
S5670	078	0		29	10	S5670_078_0	2	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					20.00		60.00																						20.00		50.00																		20.00					20.00							
S5670	078	0		29	10	S5670_078_0	2	3	Preferred Brand	1	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					41.86	25		25																					25		25																	25							25			
S5670	078	0		29	10	S5670_078_0	2	4	Non-Preferred Brand	1	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					57.50	43		43																					43		43																	43				43			43			
S5670	084	0		29	10	S5670_084_0	2	4	Non-Preferred Brand	1	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					54.88	41		41																					41		41																	41				41			41			
S5670	084	0		29	10	S5670_084_0	2	3	Preferred Brand	1	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					39.41	25		25																					25		25																	25							25			
S5670	084	0		29	10	S5670_084_0	2	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					20.00		60.00																						20.00		50.00																		20.00					20.00							
S5670	084	0		29	10	S5670_084_0	2	1	Preferred Generic	1	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00							
S5670	084	0		29	10	S5670_084_0	2	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					420.84	33																																										33				33			33			
S5670	084	0		29	10	S5670_084_0	2	1	Preferred Generic	3	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					3.00		9.00																						3.00		7.50																		3.00					3.00					1		
S5670	084	0		29	10	S5670_084_0	2	3	Preferred Brand	3	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					192.08	25		25																					25		25																	25							25	2		1
S5670	084	0		29	10	S5670_084_0	2	4	Non-Preferred Brand	3	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					184.05	41		41																					41		41																	41				41			41	2	1	
S5670	090	0		29	10	S5670_090_0	2	4	Non-Preferred Brand	3	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					183.95	43		43																					43		43																	43				43			43	2	1	
S5670	090	0		29	10	S5670_090_0	2	3	Preferred Brand	3	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					185.03	25		25																					25		25																	25							25	2		1
S5670	090	0		29	10	S5670_090_0	2	4	Non-Preferred Brand	1	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					57.64	43		43																					43		43																	43				43			43			
S5670	090	0		29	10	S5670_090_0	2	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					464.14	33																																										33				33			33			
S5670	090	0		29	10	S5670_090_0	2	1	Preferred Generic	3	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					3.00		9.00																						3.00		7.50																		3.00					3.00					1		
S5670	090	0		29	10	S5670_090_0	2	3	Preferred Brand	1	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					39.07	25		25																					25		25																	25							25			
S5670	090	0		29	10	S5670_090_0	2	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					20.00		60.00																						20.00		50.00																		20.00					20.00							
S5670	090	0		29	10	S5670_090_0	2	1	Preferred Generic	1	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00							
S5670	096	0		29	10	S5670_096_0	2	4	Non-Preferred Brand	1	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					56.99	41		41																					41		41																	41				41			41			
S5670	096	0		29	10	S5670_096_0	2	3	Preferred Brand	1	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					38.94	25		25																					25		25																	25							25			
S5670	096	0		29	10	S5670_096_0	2	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					20.00		60.00																						20.00		50.00																		20.00					20.00							
S5670	096	0		29	10	S5670_096_0	2	1	Preferred Generic	1	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00							
S5670	096	0		29	10	S5670_096_0	2	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					433.73	33																																										33				33			33			
S5670	096	0		29	10	S5670_096_0	2	1	Preferred Generic	3	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					3.00		9.00																						3.00		7.50																		3.00					3.00					1		
S5670	096	0		29	10	S5670_096_0	2	3	Preferred Brand	3	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					194.91	25		25																					25		25																	25							25	2		1
S5670	096	0		29	10	S5670_096_0	2	4	Non-Preferred Brand	3	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					196.34	41		41																					41		41																	41				41			41	2	1	
S5670	102	0		29	10	S5670_102_0	1	3	Preferred Brand	3	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					192.01	25		25																					25		25																	25							25	2		1
S5670	102	0		29	10	S5670_102_0	1	1	Preferred Generic	3	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					3.00		9.00																						3.00		7.50																		3.00					3.00					1		
S5670	102	0		29	10	S5670_102_0	1	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					319.36	33																																										33				33			33			
S5670	102	0		29	10	S5670_102_0	1	4	Non-Preferred Brand	1	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					66.45	43		43																					43		43																	43				43			43			
S5670	102	0		29	10	S5670_102_0	1	3	Preferred Brand	1	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					39.36	25		25																					25		25																	25							25			
S5670	102	0		29	10	S5670_102_0	1	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					20.00		60.00																						20.00		50.00																		20.00					20.00							
S5670	102	0		29	10	S5670_102_0	1	1	Preferred Generic	1	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00							
S5670	102	0		29	10	S5670_102_0	1	4	Non-Preferred Brand	3	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					222.41	43		43																					43		43																	43				43			43	2	1	
S5670	108	0		29	10	S5670_108_0	2	4	Non-Preferred Brand	3	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					159.26	43		43																					43		43																	43				43			43	2	1	
S5670	108	0		29	10	S5670_108_0	2	3	Preferred Brand	3	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					195.32	25		25																					25		25																	25							25	2		1
S5670	108	0		29	10	S5670_108_0	2	1	Preferred Generic	3	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					3.00		9.00																						3.00		7.50																		3.00					3.00					1		
S5670	108	0		29	10	S5670_108_0	2	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					481.48	33																																										33				33			33			
S5670	108	0		29	10	S5670_108_0	2	4	Non-Preferred Brand	1	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					50.55	43		43																					43		43																	43				43			43			
S5670	108	0		29	10	S5670_108_0	2	3	Preferred Brand	1	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					40.16	25		25																					25		25																	25							25			
S5670	108	0		29	10	S5670_108_0	2	1	Preferred Generic	1	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00							
S5670	108	0		29	10	S5670_108_0	2	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					20.00		60.00																						20.00		50.00																		20.00					20.00							
S5670	114	0		29	10	S5670_114_0	2	1	Preferred Generic	1	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00							
S5670	114	0		29	10	S5670_114_0	2	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					20.00		60.00																						20.00		50.00																		20.00					20.00							
S5670	114	0		29	10	S5670_114_0	2	3	Preferred Brand	1	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					39.32	25		25																					25		25																	25							25			
S5670	114	0		29	10	S5670_114_0	2	4	Non-Preferred Brand	1	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					55.29	43		43																					43		43																	43				43			43			
S5670	114	0		29	10	S5670_114_0	2	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					464.38	33																																										33				33			33			
S5670	114	0		29	10	S5670_114_0	2	1	Preferred Generic	3	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					3.00		9.00																						3.00		7.50																		3.00					3.00					1		
S5670	114	0		29	10	S5670_114_0	2	3	Preferred Brand	3	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					191.08	25		25																					25		25																	25							25	2		1
S5670	114	0		29	10	S5670_114_0	2	4	Non-Preferred Brand	3	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					189.08	43		43																					43		43																	43				43			43	2	1	
S5670	120	0		29	10	S5670_120_0	2	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					20.00		60.00																						20.00		50.00																		20.00					20.00							
S5670	120	0		29	10	S5670_120_0	2	3	Preferred Brand	1	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					40.27	25		25																					25		25																	25							25			
S5670	120	0		29	10	S5670_120_0	2	4	Non-Preferred Brand	1	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					56.90	43		43																					43		43																	43				43			43			
S5670	120	0		29	10	S5670_120_0	2	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					431.87	33																																										33				33			33			
S5670	120	0		29	10	S5670_120_0	2	1	Preferred Generic	3	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					3.00		9.00																						3.00		7.50																		3.00					3.00					1		
S5670	120	0		29	10	S5670_120_0	2	3	Preferred Brand	3	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					198.36	25		25																					25		25																	25							25	2		1
S5670	120	0		29	10	S5670_120_0	2	4	Non-Preferred Brand	3	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					177.16	43		43																					43		43																	43				43			43	2	1	
S5670	120	0		29	10	S5670_120_0	2	1	Preferred Generic	1	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00							
S5670	126	0		29	10	S5670_126_0	2	1	Preferred Generic	3	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					3.00		9.00																						3.00		7.50																		3.00					3.00					1		
S5670	126	0		29	10	S5670_126_0	2	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					20.00		60.00																						20.00		50.00																		20.00					20.00							
S5670	126	0		29	10	S5670_126_0	2	4	Non-Preferred Brand	1	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					61.84	43		43																					43		43																	43				43			43			
S5670	126	0		29	10	S5670_126_0	2	3	Preferred Brand	1	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					37.01	25		25																					25		25																	25							25			
S5670	126	0		29	10	S5670_126_0	2	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					369.51	33																																										33				33			33			
S5670	126	0		29	10	S5670_126_0	2	1	Preferred Generic	1	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00							
S5670	126	0		29	10	S5670_126_0	2	3	Preferred Brand	3	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					177.86	25		25																					25		25																	25							25	2		1
S5670	126	0		29	10	S5670_126_0	2	4	Non-Preferred Brand	3	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					190.44	43		43																					43		43																	43				43			43	2	1	
S5670	132	0		29	10	S5670_132_0	2	3	Preferred Brand	1	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					38.01	25		25																					25		25																	25							25			
S5670	132	0		29	10	S5670_132_0	2	1	Preferred Generic	1	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00							
S5670	132	0		29	10	S5670_132_0	2	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					20.00		60.00																						20.00		50.00																		20.00					20.00							
S5670	132	0		29	10	S5670_132_0	2	4	Non-Preferred Brand	3	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					168.73	41		41																					41		41																	41				41			41	2	1	
S5670	132	0		29	10	S5670_132_0	2	3	Preferred Brand	3	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					183.28	25		25																					25		25																	25							25	2		1
S5670	132	0		29	10	S5670_132_0	2	1	Preferred Generic	3	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					3.00		9.00																						3.00		7.50																		3.00					3.00					1		
S5670	132	0		29	10	S5670_132_0	2	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					362.14	33																																										33				33			33			
S5670	132	0		29	10	S5670_132_0	2	4	Non-Preferred Brand	1	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					52.33	41		41																					41		41																	41				41			41			
S5670	138	0		29	10	S5670_138_0	2	4	Non-Preferred Brand	3	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					196.03	41		41																					41		41																	41				41			41	2	1	
S5670	138	0		29	10	S5670_138_0	2	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					20.00		60.00																						20.00		50.00																		20.00					20.00							
S5670	138	0		29	10	S5670_138_0	2	3	Preferred Brand	1	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					43.00	25		25																					25		25																	25							25			
S5670	138	0		29	10	S5670_138_0	2	4	Non-Preferred Brand	1	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					59.93	41		41																					41		41																	41				41			41			
S5670	138	0		29	10	S5670_138_0	2	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					318.35	33																																										33				33			33			
S5670	138	0		29	10	S5670_138_0	2	1	Preferred Generic	1	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00							
S5670	138	0		29	10	S5670_138_0	2	3	Preferred Brand	3	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					209.35	25		25																					25		25																	25							25	2		1
S5670	138	0		29	10	S5670_138_0	2	1	Preferred Generic	3	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					3.00		9.00																						3.00		7.50																		3.00					3.00					1		
S5670	144	0		29	10	S5670_144_0	2	4	Non-Preferred Brand	3	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					176.04	44		44																					44		44																	44				44			44	2	1	
S5670	144	0		29	10	S5670_144_0	2	3	Preferred Brand	3	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					203.95	25		25																					25		25																	25							25	2		1
S5670	144	0		29	10	S5670_144_0	2	1	Preferred Generic	3	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					5.00		15.00																						5.00		12.50																		5.00					5.00					1		
S5670	144	0		29	10	S5670_144_0	2	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					359.20	33																																										33				33			33			
S5670	144	0		29	10	S5670_144_0	2	4	Non-Preferred Brand	1	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					53.76	42		42																					42		42																	42				42			42			
S5670	144	0		29	10	S5670_144_0	2	3	Preferred Brand	1	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					39.64	25		25																					25		25																	25							25			
S5670	144	0		29	10	S5670_144_0	2	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					20.00		60.00																						20.00		50.00																		20.00					20.00							
S5670	144	0		29	10	S5670_144_0	2	1	Preferred Generic	1	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00							
S5670	150	0		29	10	S5670_150_0	2	1	Preferred Generic	1	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00							
S5670	150	0		29	10	S5670_150_0	2	1	Preferred Generic	3	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					3.00		9.00																						3.00		7.50																		3.00					3.00					1		
S5670	150	0		29	10	S5670_150_0	2	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					408.79	33																																										33				33			33			
S5670	150	0		29	10	S5670_150_0	2	4	Non-Preferred Brand	1	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					57.41	43		43																					43		43																	43				43			43			
S5670	150	0		29	10	S5670_150_0	2	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					20.00		60.00																						20.00		50.00																		20.00					20.00							
S5670	150	0		29	10	S5670_150_0	2	3	Preferred Brand	1	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					39.19	25		25																					25		25																	25							25			
S5670	150	0		29	10	S5670_150_0	2	3	Preferred Brand	3	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					190.75	25		25																					25		25																	25							25	2		1
S5670	150	0		29	10	S5670_150_0	2	4	Non-Preferred Brand	3	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					188.09	45		45																					45		45																	45				45			45	2	1	
S5674	005	0		29	10	S5674_005_0	2	4	Non-Preferred Brand	3	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					185.89	43		43																					43		43																	43				43			43	2	1	
S5674	005	0		29	10	S5674_005_0	2	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					343.85	33																																										33				33			33			
S5674	005	0		29	10	S5674_005_0	2	4	Non-Preferred Brand	1	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					53.29	43		43																					43		43																	43				43			43			
S5674	005	0		29	10	S5674_005_0	2	3	Preferred Brand	1	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					38.31	25		25																					25		25																	25							25			
S5674	005	0		29	10	S5674_005_0	2	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					20.00		60.00																						20.00		50.00																		20.00					20.00							
S5674	005	0		29	10	S5674_005_0	2	1	Preferred Generic	1	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00							
S5674	005	0		29	10	S5674_005_0	2	3	Preferred Brand	3	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					194.07	25		25																					25		25																	25							25	2		1
S5674	005	0		29	10	S5674_005_0	2	1	Preferred Generic	3	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					3.00		9.00																						3.00		7.50																		3.00					3.00					1		
S5674	011	0		29	10	S5674_011_0	2	4	Non-Preferred Brand	3	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					199.93	41		41																					41		41																	41				41			41	2	1	
S5674	011	0		29	10	S5674_011_0	2	3	Preferred Brand	3	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					202.05	25		25																					25		25																	25							25	2		1
S5674	011	0		29	10	S5674_011_0	2	1	Preferred Generic	1	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00							
S5674	011	0		29	10	S5674_011_0	2	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					20.00		60.00																						20.00		50.00																		20.00					20.00							
S5674	011	0		29	10	S5674_011_0	2	3	Preferred Brand	1	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					40.52	25		25																					25		25																	25							25			
S5674	011	0		29	10	S5674_011_0	2	4	Non-Preferred Brand	1	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					58.12	41		41																					41		41																	41				41			41			
S5674	011	0		29	10	S5674_011_0	2	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					403.99	33																																										33				33			33			
S5674	011	0		29	10	S5674_011_0	2	1	Preferred Generic	3	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					3.00		9.00																						3.00		7.50																		3.00					3.00					1		
S5674	017	0		29	10	S5674_017_0	2	4	Non-Preferred Brand	3	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					199.02	43		43																					43		43																	43				43			43	2	1	
S5674	017	0		29	10	S5674_017_0	2	1	Preferred Generic	1	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00							
S5674	017	0		29	10	S5674_017_0	2	3	Preferred Brand	3	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					200.62	25		25																					25		25																	25							25	2		1
S5674	017	0		29	10	S5674_017_0	2	1	Preferred Generic	3	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					3.00		9.00																						3.00		7.50																		3.00					3.00					1		
S5674	017	0		29	10	S5674_017_0	2	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					425.37	33																																										33				33			33			
S5674	017	0		29	10	S5674_017_0	2	4	Non-Preferred Brand	1	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					60.77	43		43																					43		43																	43				43			43			
S5674	017	0		29	10	S5674_017_0	2	3	Preferred Brand	1	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					40.44	25		25																					25		25																	25							25			
S5674	017	0		29	10	S5674_017_0	2	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					20.00		60.00																						20.00		50.00																		20.00					20.00							
S5674	023	0		29	10	S5674_023_0	2	4	Non-Preferred Brand	3	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					177.63	43		43																					43		43																	43				43			43	2	1	
S5674	023	0		29	10	S5674_023_0	2	3	Preferred Brand	3	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					191.99	25		25																					25		25																	25							25	2		1
S5674	023	0		29	10	S5674_023_0	2	1	Preferred Generic	3	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					3.00		9.00																						3.00		7.50																		3.00					3.00					1		
S5674	023	0		29	10	S5674_023_0	2	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					448.22	33																																										33				33			33			
S5674	023	0		29	10	S5674_023_0	2	4	Non-Preferred Brand	1	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					55.03	43		43																					43		43																	43				43			43			
S5674	023	0		29	10	S5674_023_0	2	3	Preferred Brand	1	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					39.86	25		25																					25		25																	25							25			
S5674	023	0		29	10	S5674_023_0	2	1	Preferred Generic	1	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00							
S5674	023	0		29	10	S5674_023_0	2	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					20.00		60.00																						20.00		50.00																		20.00					20.00							
S5674	029	0		29	10	S5674_029_0	2	3	Preferred Brand	3	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					200.00	25		25																					25		25																	25							25	2		1
S5674	029	0		29	10	S5674_029_0	2	1	Preferred Generic	3	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					3.00		9.00																						3.00		7.50																		3.00					3.00					1		
S5674	029	0		29	10	S5674_029_0	2	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					364.38	33																																										33				33			33			
S5674	029	0		29	10	S5674_029_0	2	4	Non-Preferred Brand	1	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					53.46	41		41																					41		41																	41				41			41			
S5674	029	0		29	10	S5674_029_0	2	3	Preferred Brand	1	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					40.81	25		25																					25		25																	25							25			
S5674	029	0		29	10	S5674_029_0	2	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					20.00		60.00																						20.00		50.00																		20.00					20.00							
S5674	029	0		29	10	S5674_029_0	2	1	Preferred Generic	1	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00							
S5674	029	0		29	10	S5674_029_0	2	4	Non-Preferred Brand	3	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					175.04	41		41																					41		41																	41				41			41	2	1	
S5674	035	0		29	10	S5674_035_0	2	4	Non-Preferred Brand	3	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					168.80	41		41																					41		41																	41				41			41	2	1	
S5674	035	0		29	10	S5674_035_0	2	1	Preferred Generic	1	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00							
S5674	035	0		29	10	S5674_035_0	2	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					20.00		60.00																						20.00		50.00																		20.00					20.00							
S5674	035	0		29	10	S5674_035_0	2	3	Preferred Brand	1	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					37.70	25		25																					25		25																	25							25			
S5674	035	0		29	10	S5674_035_0	2	4	Non-Preferred Brand	1	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					50.34	41		41																					41		41																	41				41			41			
S5674	035	0		29	10	S5674_035_0	2	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					319.46	33																																										33				33			33			
S5674	035	0		29	10	S5674_035_0	2	1	Preferred Generic	3	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					3.00		9.00																						3.00		7.50																		3.00					3.00					1		
S5674	035	0		29	10	S5674_035_0	2	3	Preferred Brand	3	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					187.61	25		25																					25		25																	25							25	2		1
S5674	041	0		29	10	S5674_041_0	2	1	Preferred Generic	1	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00							
S5674	041	0		29	10	S5674_041_0	2	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					20.00		60.00																						20.00		50.00																		20.00					20.00							
S5674	041	0		29	10	S5674_041_0	2	3	Preferred Brand	1	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					42.80	25		25																					25		25																	25							25			
S5674	041	0		29	10	S5674_041_0	2	4	Non-Preferred Brand	1	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					59.69	43		43																					43		43																	43				43			43			
S5674	041	0		29	10	S5674_041_0	2	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					461.51	33																																										33				33			33			
S5674	041	0		29	10	S5674_041_0	2	1	Preferred Generic	3	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					3.00		9.00																						3.00		7.50																		3.00					3.00					1		
S5674	041	0		29	10	S5674_041_0	2	3	Preferred Brand	3	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					243.76	25		25																					25		25																	25							25	2		1
S5674	041	0		29	10	S5674_041_0	2	4	Non-Preferred Brand	3	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					196.77	43		43																					43		43																	43				43			43	2	1	
S5674	047	0		29	10	S5674_047_0	2	4	Non-Preferred Brand	3	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					172.72	41		41																					41		41																	41				41			41	2	1	
S5674	047	0		29	10	S5674_047_0	2	3	Preferred Brand	3	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					191.37	25		25																					25		25																	25							25	2		1
S5674	047	0		29	10	S5674_047_0	2	1	Preferred Generic	3	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					3.00		9.00																						3.00		7.50																		3.00					3.00					1		
S5674	047	0		29	10	S5674_047_0	2	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					347.68	33																																										33				33			33			
S5674	047	0		29	10	S5674_047_0	2	4	Non-Preferred Brand	1	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					52.50	41		41																					41		41																	41				41			41			
S5674	047	0		29	10	S5674_047_0	2	3	Preferred Brand	1	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					38.01	25		25																					25		25																	25							25			
S5674	047	0		29	10	S5674_047_0	2	1	Preferred Generic	1	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00							
S5674	047	0		29	10	S5674_047_0	2	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					20.00		60.00																						20.00		50.00																		20.00					20.00							
S5674	053	0		29	10	S5674_053_0	2	1	Preferred Generic	1	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00							
S5674	053	0		29	10	S5674_053_0	2	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					20.00		60.00																						20.00		50.00																		20.00					20.00							
S5674	053	0		29	10	S5674_053_0	2	3	Preferred Brand	1	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					36.22	25		25																					25		25																	25							25			
S5674	053	0		29	10	S5674_053_0	2	4	Non-Preferred Brand	1	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					53.14	40		40																					40		40																	40				40			40			
S5674	053	0		29	10	S5674_053_0	2	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					329.83	33																																										33				33			33			
S5674	053	0		29	10	S5674_053_0	2	1	Preferred Generic	3	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					3.00		9.00																						3.00		7.50																		3.00					3.00					1		
S5674	053	0		29	10	S5674_053_0	2	3	Preferred Brand	3	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					179.94	25		25																					25		25																	25							25	2		1
S5674	053	0		29	10	S5674_053_0	2	4	Non-Preferred Brand	3	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					197.02	40		40																					40		40																	40				40			40	2	1	
S5674	059	0		29	10	S5674_059_0	2	1	Preferred Generic	1	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00							
S5674	059	0		29	10	S5674_059_0	2	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					20.00		60.00																						20.00		50.00																		20.00					20.00							
S5674	059	0		29	10	S5674_059_0	2	3	Preferred Brand	1	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					38.92	25		25																					25		25																	25							25			
S5674	059	0		29	10	S5674_059_0	2	4	Non-Preferred Brand	1	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					61.03	43		43																					43		43																	43				43			43			
S5674	059	0		29	10	S5674_059_0	2	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					441.11	33																																										33				33			33			
S5674	059	0		29	10	S5674_059_0	2	1	Preferred Generic	3	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					3.00		9.00																						3.00		7.50																		3.00					3.00					1		
S5674	059	0		29	10	S5674_059_0	2	3	Preferred Brand	3	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					189.90	25		25																					25		25																	25							25	2		1
S5674	059	0		29	10	S5674_059_0	2	4	Non-Preferred Brand	3	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					191.92	43		43																					43		43																	43				43			43	2	1	
S5674	065	0		29	10	S5674_065_0	2	3	Preferred Brand	3	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					228.11	33		33																					33		33																	33							33	2		1
S5674	065	0		29	10	S5674_065_0	2	1	Preferred Generic	3	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					7.00		21.00																						7.00		17.50																		7.00					7.00					1		
S5674	065	0		29	10	S5674_065_0	2	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					322.03	33																																										33				33			33			
S5674	065	0		29	10	S5674_065_0	2	4	Non-Preferred Brand	1	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					75.92	50		50																					50		50																	50				50			50			
S5674	065	0		29	10	S5674_065_0	2	3	Preferred Brand	1	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					43.43	25		25																					25		25																	25							25			
S5674	065	0		29	10	S5674_065_0	2	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					25.00		75.00																						25.00		62.50																		25.00					25.00							
S5674	065	0		29	10	S5674_065_0	2	1	Preferred Generic	1	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00							
S5674	065	0		29	10	S5674_065_0	2	4	Non-Preferred Brand	3	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					219.33	55		55																					55		55																	55				55			55	2	1	
S5674	071	0		29	10	S5674_071_0	2	1	Preferred Generic	1	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					0.00		0.00																						0.00		0.00																		0.00					0.00							
S5674	071	0		29	10	S5674_071_0	2	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							2	30		90							30		31					25.00		75.00																						25.00		62.50																		25.00					25.00							
S5674	071	0		29	10	S5674_071_0	2	3	Preferred Brand	1	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					36.97	25		25																					25		25																	25							25			
S5674	071	0		29	10	S5674_071_0	2	4	Non-Preferred Brand	1	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					63.23	50		50																					50		50																	50				50			50			
S5674	071	0		29	10	S5674_071_0	2	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					378.33	33																																										33				33			33			
S5674	071	0		29	10	S5674_071_0	2	1	Preferred Generic	3	4	001000	3	2	010100000010101000000100	30		90							2	30		90							30		31					7.00		21.00																						7.00		17.50																		7.00					7.00					1		
S5674	071	0		29	10	S5674_071_0	2	3	Preferred Brand	3	4	000001	3	1	110100000010101000000001	30		90							2	30		90							30				31	14					182.10	33		33																					33		33																	33							33	2		1
S5674	071	0		29	10	S5674_071_0	2	4	Non-Preferred Brand	3	4	100100	1	1	110100000010101000000101	30		90							2	30		90							30		31		31	14					175.36	55		55																					55		55																	55				55			55	2	1	
S5715	001	0		29	10	S5715_001_0	6	1	Preferred Generic	1	3	001000		2	000010110110001000000100				30		90	30		90	1			90							30		31													3.00		7.50						3.00		9.00								7.50																		3.00					3.00							
S5715	001	0		29	10	S5715_001_0	6	2	Non-Preferred Generic	1	3	000100		2	000010110110001000000100				30		90	30		90	1			90							30		31													11.00		27.50						11.00		33.00								27.50																		11.00					11.00							
S5715	001	0		29	10	S5715_001_0	6	3	Preferred Brand	1	3	000001		2	100010110110001000000001				30		90	30		90	1			90							30				31	14										44.00		110.00						44.00		132.00								110.00																		44.00								44.00				
S5715	001	0		29	10	S5715_001_0	6	4	Non-Preferred Brand	1	3	100000		2	100010110110001000000001				30		90	30		90	1			90							30				31	14										95.00		237.50						95.00		285.00								237.50																		95.00								95.00				
S5715	001	0		29	10	S5715_001_0	6	5	Specialty Tier	1	3	010010		1	100010110110000000000101				30		90	30		90	1										30		31		31	14													940.00	25		25					940.00	25		25																								25				25			25			
S5715	002	0		29	10	S5715_002_0	4	2	Non-Preferred Generic	1	4	000100	1	2	000010110110001000000100				30		90	30		90	1			90							30		31													10.00		25.00						10.00		30.00								25.00																		10.00					10.00							
S5715	002	0		29	10	S5715_002_0	4	1	Preferred Generic	1	4	001000	1	2	000010110110001000000100				30		90	30		90	1			90							30		31													3.00		7.50						3.00		9.00								7.50																		3.00					3.00							
S5715	002	0		29	10	S5715_002_0	4	3	Preferred Brand	1	4	000001	1	2	100010110110001000000001				30		90	30		90	1			90							30				31	14										38.00		95.00						38.00		114.00								95.00																		38.00								38.00				
S5715	002	0		29	10	S5715_002_0	4	4	Non-Preferred Brand	1	4	100000	1	2	100010110110001000000001				30		90	30		90	1			90							30				31	14										86.00		215.00						86.00		258.00								215.00																		86.00								86.00				
S5715	002	0		29	10	S5715_002_0	4	5	Specialty Tier	1	4	010010	1	1	100010110110000000000101				30		90	30		90	1										30		31		31	14													1210.00	33		33					1210.00	33		33																								33				33			33			
S5715	002	0		29	10	S5715_002_0	4	5	Specialty Tier	3	4	010010	1	1	100010110110000000000101				30		90	30		90	1										30		31		31	14													380.00	33		33					380.00	33		33																								33				33			33	2	2	
S5715	002	0		29	10	S5715_002_0	4	2	Non-Preferred Generic	3	4	000100	1	2	000010110110001000000100				30		90	30		90	1			90							30		31													10.00		25.00						10.00		30.00								25.00																		10.00					10.00					1		
S5715	002	0		29	10	S5715_002_0	4	1	Preferred Generic	3	4	001000	1	2	000010110110001000000100				30		90	30		90	1			90							30		31													3.00		7.50						3.00		9.00								7.50																		3.00					3.00					1		
S5715	003	0		29	10	S5715_003_0	5	5	Specialty Tier	1	3	010010		1	100010110110000000000101				30		90	30		90	1										30		31		31	14													1030.00	25		25					1030.00	25		25																								25				25			25			
S5715	003	0		29	10	S5715_003_0	5	4	Non-Preferred Brand	1	3	100000		2	100010110110001000000001				30		90	30		90	1			90							30				31	14										95.00		237.50						95.00		285.00								237.50																		95.00								95.00				
S5715	003	0		29	10	S5715_003_0	5	3	Preferred Brand	1	3	000001		2	100010110110001000000001				30		90	30		90	1			90							30				31	14										45.00		112.50						45.00		135.00								112.50																		45.00								45.00				
S5715	003	0		29	10	S5715_003_0	5	2	Non-Preferred Generic	1	3	000100		2	000010110110001000000100				30		90	30		90	1			90							30		31													14.00		35.00						14.00		42.00								35.00																		14.00					14.00							
S5715	003	0		29	10	S5715_003_0	5	1	Preferred Generic	1	3	001000		2	000010110110001000000100				30		90	30		90	1			90							30		31													3.00		7.50						3.00		9.00								7.50																		3.00					3.00							
S5715	004	0		29	10	S5715_004_0	3	4	Non-Preferred Brand	1	4	100000	1	2	100010110110001000000001				30		90	30		90	1			90							30				31	14										86.00		215.00						86.00		258.00								215.00																		86.00								86.00				
S5715	004	0		29	10	S5715_004_0	3	5	Specialty Tier	1	4	010010	1	1	100010110110000000000101				30		90	30		90	1										30		31		31	14													1210.00	33		33					1210.00	33		33																								33				33			33			
S5715	004	0		29	10	S5715_004_0	3	3	Preferred Brand	1	4	000001	1	2	100010110110001000000001				30		90	30		90	1			90							30				31	14										38.00		95.00						38.00		114.00								95.00																		38.00								38.00				
S5715	004	0		29	10	S5715_004_0	3	2	Non-Preferred Generic	1	4	000100	1	2	000010110110001000000100				30		90	30		90	1			90							30		31													10.00		25.00						10.00		30.00								25.00																		10.00					10.00							
S5715	004	0		29	10	S5715_004_0	3	1	Preferred Generic	1	4	001000	1	2	000010110110001000000100				30		90	30		90	1			90							30		31													3.00		7.50						3.00		9.00								7.50																		3.00					3.00							
S5715	004	0		29	10	S5715_004_0	3	5	Specialty Tier	3	4	010010	1	1	100010110110000000000101				30		90	30		90	1										30		31		31	14													380.00	33		33					380.00	33		33																								33				33			33	2	2	
S5715	004	0		29	10	S5715_004_0	3	2	Non-Preferred Generic	3	4	000100	1	2	000010110110001000000100				30		90	30		90	1			90							30		31													10.00		25.00						10.00		30.00								25.00																		10.00					10.00					1		
S5715	004	0		29	10	S5715_004_0	3	1	Preferred Generic	3	4	001000	1	2	000010110110001000000100				30		90	30		90	1			90							30		31													3.00		7.50						3.00		9.00								7.50																		3.00					3.00					1		
S5715	005	0		29	10	S5715_005_0	4	2	Non-Preferred Generic	1	3	000100		2	000010110110001000000100				30		90	30		90	1			90							30		31													10.00		25.00						10.00		30.00								25.00																		10.00					10.00							
S5715	005	0		29	10	S5715_005_0	4	3	Preferred Brand	1	3	000001		2	100010110110001000000001				30		90	30		90	1			90							30				31	14										40.00		100.00						40.00		120.00								100.00																		40.00								40.00				
S5715	005	0		29	10	S5715_005_0	4	4	Non-Preferred Brand	1	3	100000		2	100010110110001000000001				30		90	30		90	1			90							30				31	14										95.00		237.50						95.00		285.00								237.50																		95.00								95.00				
S5715	005	0		29	10	S5715_005_0	4	5	Specialty Tier	1	3	010010		1	100010110110000000000101				30		90	30		90	1										30		31		31	14													970.00	25		25					970.00	25		25																								25				25			25			
S5715	005	0		29	10	S5715_005_0	4	1	Preferred Generic	1	3	001000		2	000010110110001000000100				30		90	30		90	1			90							30		31													3.00		7.50						3.00		9.00								7.50																		3.00					3.00							
S5715	006	0		29	10	S5715_006_0	3	3	Preferred Brand	1	4	000001	1	2	100010110110001000000001				30		90	30		90	1			90							30				31	14										38.00		95.00						38.00		114.00								95.00																		38.00								38.00				
S5715	006	0		29	10	S5715_006_0	3	4	Non-Preferred Brand	1	4	100000	1	2	100010110110001000000001				30		90	30		90	1			90							30				31	14										86.00		215.00						86.00		258.00								215.00																		86.00								86.00				
S5715	006	0		29	10	S5715_006_0	3	5	Specialty Tier	1	4	010010	1	1	100010110110000000000101				30		90	30		90	1										30		31		31	14													1210.00	33		33					1210.00	33		33																								33				33			33			
S5715	006	0		29	10	S5715_006_0	3	2	Non-Preferred Generic	3	4	000100	1	2	000010110110001000000100				30		90	30		90	1			90							30		31													10.00		25.00						10.00		30.00								25.00																		10.00					10.00					1		
S5715	006	0		29	10	S5715_006_0	3	1	Preferred Generic	3	4	001000	1	2	000010110110001000000100				30		90	30		90	1			90							30		31													3.00		7.50						3.00		9.00								7.50																		3.00					3.00					1		
S5715	006	0		29	10	S5715_006_0	3	5	Specialty Tier	3	4	010010	1	1	100010110110000000000101				30		90	30		90	1										30		31		31	14													380.00	33		33					380.00	33		33																								33				33			33	2	2	
S5715	006	0		29	10	S5715_006_0	3	1	Preferred Generic	1	4	001000	1	2	000010110110001000000100				30		90	30		90	1			90							30		31													3.00		7.50						3.00		9.00								7.50																		3.00					3.00							
S5715	006	0		29	10	S5715_006_0	3	2	Non-Preferred Generic	1	4	000100	1	2	000010110110001000000100				30		90	30		90	1			90							30		31													10.00		25.00						10.00		30.00								25.00																		10.00					10.00							
S5715	010	0		29	10	S5715_010_0	4	1	Preferred Generic	1	3	001000		2	000010110110001000000100				30		90	30		90	1			90							30		31													3.00		7.50						3.00		9.00								7.50																		3.00					3.00							
S5715	010	0		29	10	S5715_010_0	4	2	Non-Preferred Generic	1	3	000100		2	000010110110001000000100				30		90	30		90	1			90							30		31													10.00		25.00						10.00		30.00								25.00																		10.00					10.00							
S5715	010	0		29	10	S5715_010_0	4	3	Preferred Brand	1	3	000001		2	100010110110001000000001				30		90	30		90	1			90							30				31	14										38.00		95.00						38.00		114.00								95.00																		38.00								38.00				
S5715	010	0		29	10	S5715_010_0	4	4	Non-Preferred Brand	1	3	100000		2	100010110110001000000001				30		90	30		90	1			90							30				31	14										95.00		237.50						95.00		285.00								237.50																		95.00								95.00				
S5715	010	0		29	10	S5715_010_0	4	5	Specialty Tier	1	3	010010		1	100010110110000000000101				30		90	30		90	1										30		31		31	14													1020.00	25		25					1020.00	25		25																								25				25			25			
S5715	011	0		29	10	S5715_011_0	3	2	Non-Preferred Generic	3	4	000100	1	2	000010110110001000000100				30		90	30		90	1			90							30		31													10.00		25.00						10.00		30.00								25.00																		10.00					10.00					1		
S5715	011	0		29	10	S5715_011_0	3	5	Specialty Tier	3	4	010010	1	1	100010110110000000000101				30		90	30		90	1										30		31		31	14													380.00	33		33					380.00	33		33																								33				33			33	2	2	
S5715	011	0		29	10	S5715_011_0	3	5	Specialty Tier	1	4	010010	1	1	100010110110000000000101				30		90	30		90	1										30		31		31	14													1210.00	33		33					1210.00	33		33																								33				33			33			
S5715	011	0		29	10	S5715_011_0	3	4	Non-Preferred Brand	1	4	100000	1	2	100010110110001000000001				30		90	30		90	1			90							30				31	14										86.00		215.00						86.00		258.00								215.00																		86.00								86.00				
S5715	011	0		29	10	S5715_011_0	3	1	Preferred Generic	1	4	001000	1	2	000010110110001000000100				30		90	30		90	1			90							30		31													3.00		7.50						3.00		9.00								7.50																		3.00					3.00							
S5715	011	0		29	10	S5715_011_0	3	1	Preferred Generic	3	4	001000	1	2	000010110110001000000100				30		90	30		90	1			90							30		31													3.00		7.50						3.00		9.00								7.50																		3.00					3.00					1		
S5715	011	0		29	10	S5715_011_0	3	3	Preferred Brand	1	4	000001	1	2	100010110110001000000001				30		90	30		90	1			90							30				31	14										38.00		95.00						38.00		114.00								95.00																		38.00								38.00				
S5715	011	0		29	10	S5715_011_0	3	2	Non-Preferred Generic	1	4	000100	1	2	000010110110001000000100				30		90	30		90	1			90							30		31													10.00		25.00						10.00		30.00								25.00																		10.00					10.00							
S5726	013	0		29	10	S5726_013_0	5	1	Preferred Generic	1	2	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5726	013	0		29	10	S5726_013_0	5	2	Non-Preferred Generic	1	2	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				6.00	12.00	18.00																						6.00	9.00	9.00																		6.00					6.00							
S5726	013	0		29	10	S5726_013_0	5	3	Preferred Brand	1	2	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		29.00	58.00	87.00																						29.00	72.50	72.50																		29.00					29.00			29.00				
S5726	013	0		29	10	S5726_013_0	5	4	Non-Preferred Brand	1	2	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		85.00	170.00	255.00																						85.00	212.50	212.50																		85.00					85.00			85.00				
S5726	013	0		29	10	S5726_013_0	5	5	Injectable Drugs	1	2	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					136.00	25	25	25																					25	25	25																	25				25			25			
S5726	013	0		29	10	S5726_013_0	5	6	Specialty Tier	1	2	010010		1	110000000010100000000111	30										30									30		34	14	34	14					674.50	25																							25																			25				25			25			
S5726	014	0		29	10	S5726_014_0	3	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					1030.26	33																							33																			33				33			33			
S5726	014	0		29	10	S5726_014_0	3	5	Injectable Drugs	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					95.70	33	33	33																					33	33	33																	33				33			33			
S5726	014	0		29	10	S5726_014_0	3	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		90.00	180.00	270.00																						90.00	225.00	225.00																		90.00					90.00			90.00				
S5726	014	0		29	10	S5726_014_0	3	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	112.50	112.50																		45.00					45.00			45.00				
S5726	014	0		29	10	S5726_014_0	3	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5726	014	0		29	10	S5726_014_0	3	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00					1		
S5726	014	0		29	10	S5726_014_0	3	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5726	015	0		29	10	S5726_015_0	3	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5726	015	0		29	10	S5726_015_0	3	3	Preferred Brand	3	4	000101	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					87.63	69	69	69																					69	69	69																	69				69			69	2	1	
S5726	015	0		29	10	S5726_015_0	3	2	Non-Preferred Generic	3	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00					1		
S5726	015	0		29	10	S5726_015_0	3	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00					1		
S5726	015	0		29	10	S5726_015_0	3	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5726	015	0		29	10	S5726_015_0	3	5	Injectable Drugs	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					77.55	33	33	33																					33	33	33																	33				33			33			
S5726	015	0		29	10	S5726_015_0	3	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		90.00	180.00	270.00																						90.00	225.00	225.00																		90.00					90.00			90.00				
S5726	015	0		29	10	S5726_015_0	3	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	112.50	112.50																		45.00					45.00			45.00				
S5726	015	0		29	10	S5726_015_0	3	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					822.03	33																							33																			33				33			33			
S5743	001	0		29	10	S5743_001_0	1	3	Preferred Brand	1	3	000001		2	111100000010001000000001	31	60	90							1			90							31				31	14		40.00	80.00	120.00																								80.00																		40.00								40.00				
S5743	001	0		29	10	S5743_001_0	1	2	Non-Preferred Generic	1	3	000100		2	011100000010001000000110	31	60	90							1			90							31		31	14				18.00	36.00	54.00																								36.00																		18.00					18.00							
S5743	001	0		29	10	S5743_001_0	1	1	Preferred Generic	1	3	001000		2	011100000010001000000110	31	60	90							1			90							31		31	14				4.00	8.00	12.00																								8.00																		4.00					4.00							
S5743	001	0		29	10	S5743_001_0	1	4	Non-Preferred Brand	1	3	100000		1	111100000010001000000001	31	60	90							1			90							31				31	14					71.57	48	48	48																							48																	48							48			
S5743	004	0		29	10	S5743_004_0	1	2	Non-Preferred Generic	3	4	000100	1	2	011100000010001000000110	31	60	90							1			90							31		31	14				12.00	24.00	36.00																								24.00																		12.00					12.00					1		
S5743	004	0		29	10	S5743_004_0	1	4	Non-Preferred Brand	1	4	100000	1	1	111100000010001000000001	31	60	90							1			90							31				31	14					78.87	48	48	48																							48																	48							48			
S5743	004	0		29	10	S5743_004_0	1	3	Preferred Brand	1	4	000001	1	2	111100000010001000000001	31	60	90							1			90							31				31	14		40.00	80.00	120.00																								80.00																		40.00								40.00				
S5743	004	0		29	10	S5743_004_0	1	2	Non-Preferred Generic	1	4	000100	1	2	011100000010001000000110	31	60	90							1			90							31		31	14				12.00	24.00	36.00																								24.00																		12.00					12.00							
S5743	004	0		29	10	S5743_004_0	1	1	Preferred Generic	1	4	001000	1	2	011100000010001000000110	31	60	90							1			90							31		31	14				4.00	8.00	12.00																								8.00																		4.00					4.00							
S5743	004	0		29	10	S5743_004_0	1	1	Preferred Generic	3	4	001000	1	2	011100000010001000000110	31	60	90							1			90							31		31	14				4.00	8.00	12.00																								8.00																		4.00					4.00					1		
S5753	006	0		29	10	S5753_006_0	3	1	Preferred Generic	1	3	001000		2	011100000001111000000100	31	60	90							1	31	60	90								29	31					6.00	12.00	18.00																						6.00	12.00	15.00																			6.00				6.00							
S5753	006	0		29	10	S5753_006_0	3	2	Non-Preferred Generic	1	3	000100		2	011100000001111000000100	31	60	90							1	31	60	90								29	31					13.00	26.00	39.00																						13.00	26.00	32.50																			13.00				13.00							
S5753	006	0		29	10	S5753_006_0	3	3	Preferred Brand	1	3	000001		2	111100000001111000000001	31	60	90							1	31	60	90								29			31	14		39.00	78.00	117.00																						39.00	78.00	97.50																			39.00							39.00				
S5753	006	0		29	10	S5753_006_0	3	4	Non-Preferred Brand	1	3	100000		1	111100000001111000000001	31	60	90							1	31	60	90								29			31	14					95.21	50	50	50																					50	50	50																		50						50			
S5753	006	0		29	10	S5753_006_0	3	5	Specialty Tier	1	3	010010		1	111100000001111000000101	31	60	90							2	31	60	90								29	31		31	14					28.00	28	28	28																					28	28	28																		28			28			28			
S5753	007	0		29	10	S5753_007_0	3	1	Preferred Generic	3	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								29	31					3.00	6.00	9.00																						3.00	6.00	7.50																			3.00				3.00					1		
S5753	007	0		29	10	S5753_007_0	3	2	Non-Preferred Generic	1	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								29	31					11.00	22.00	33.00																						11.00	22.00	27.50																			11.00				11.00							
S5753	007	0		29	10	S5753_007_0	3	3	Preferred Brand	1	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								29			31	14		39.00	78.00	117.00																						39.00	78.00	97.50																			39.00							39.00				
S5753	007	0		29	10	S5753_007_0	3	1	Preferred Generic	1	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								29	31					3.00	6.00	9.00																						3.00	6.00	7.50																			3.00				3.00							
S5753	007	0		29	10	S5753_007_0	3	5	Specialty Tier	1	4	010010	1	1	111100000001111000000101	31	60	90							2	31	60	90								29	31		31	14					33.00	33	33	33																					33	33	33																		33			33			33			
S5753	007	0		29	10	S5753_007_0	3	4	Non-Preferred Brand	1	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								29			31	14					95.21	50	50	50																					50	50	50																		50						50			
S5753	007	0		29	10	S5753_007_0	3	2	Non-Preferred Generic	3	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								29	31					11.00	22.00	33.00																						11.00	22.00	27.50																			11.00				11.00					1		
S5755	005	0		29	10	S5755_005_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													566.54	29		29					566.54	29		29							29																	29				29			29			
S5755	005	0		29	10	S5755_005_0	2	2	Non-Preferred Generic	1	4	000110	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										7.00		21.00						12.00		36.00								30.00																		12.00					12.00			12.00				
S5755	005	0		29	10	S5755_005_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										40.00		100.00						45.00		113.00								90.00																		45.00					45.00			45.00				
S5755	005	0		29	10	S5755_005_0	2	4	Non-Preferred Brand	1	4	110000	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		238.00						95.00		238.00								190.00																		95.00					95.00			95.00				
S5755	005	0		29	10	S5755_005_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	006	0		29	10	S5755_006_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	006	0		29	10	S5755_006_0	2	2	Non-Preferred Generic	1	4	000110	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										7.00		21.00						12.00		36.00								30.00																		12.00					12.00			12.00				
S5755	006	0		29	10	S5755_006_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													651.32	29		29					651.32	29		29							29																	29				29			29			
S5755	006	0		29	10	S5755_006_0	2	4	Non-Preferred Brand	1	4	110000	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		238.00						95.00		238.00								190.00																		95.00					95.00			95.00				
S5755	006	0		29	10	S5755_006_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										40.00		100.00						45.00		113.00								90.00																		45.00					45.00			45.00				
S5755	007	0		29	10	S5755_007_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													740.31	29		29					740.31	29		29							29																	29				29			29			
S5755	007	0		29	10	S5755_007_0	2	4	Non-Preferred Brand	1	4	110000	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		238.00						95.00		238.00								190.00																		95.00					95.00			95.00				
S5755	007	0		29	10	S5755_007_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										40.00		100.00						45.00		113.00								90.00																		45.00					45.00			45.00				
S5755	007	0		29	10	S5755_007_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	007	0		29	10	S5755_007_0	2	2	Non-Preferred Generic	1	4	000110	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										7.00		21.00						12.00		36.00								30.00																		12.00					12.00			12.00				
S5755	008	0		29	10	S5755_008_0	2	2	Non-Preferred Generic	1	4	000110	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										7.00		21.00						12.00		36.00								30.00																		12.00					12.00			12.00				
S5755	008	0		29	10	S5755_008_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	008	0		29	10	S5755_008_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										40.00		100.00						45.00		113.00								90.00																		45.00					45.00			45.00				
S5755	008	0		29	10	S5755_008_0	2	4	Non-Preferred Brand	1	4	110000	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		238.00						95.00		238.00								190.00																		95.00					95.00			95.00				
S5755	008	0		29	10	S5755_008_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													576.69	29		29					576.69	29		29							29																	29				29			29			
S5755	009	0		29	10	S5755_009_0	2	2	Non-Preferred Generic	1	4	000110	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										7.00		21.00						12.00		36.00								30.00																		12.00					12.00			12.00				
S5755	009	0		29	10	S5755_009_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	009	0		29	10	S5755_009_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										40.00		100.00						45.00		113.00								90.00																		45.00					45.00			45.00				
S5755	009	0		29	10	S5755_009_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													564.27	29		29					564.27	29		29							29																	29				29			29			
S5755	009	0		29	10	S5755_009_0	2	4	Non-Preferred Brand	1	4	110000	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		238.00						95.00		238.00								190.00																		95.00					95.00			95.00				
S5755	010	0		29	10	S5755_010_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	010	0		29	10	S5755_010_0	2	2	Non-Preferred Generic	1	4	000110	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										7.00		21.00						12.00		36.00								30.00																		12.00					12.00			12.00				
S5755	010	0		29	10	S5755_010_0	2	4	Non-Preferred Brand	1	4	110000	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		238.00						95.00		238.00								190.00																		95.00					95.00			95.00				
S5755	010	0		29	10	S5755_010_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										40.00		100.00						45.00		113.00								90.00																		45.00					45.00			45.00				
S5755	010	0		29	10	S5755_010_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													573.08	29		29					573.08	29		29							29																	29				29			29			
S5755	011	0		29	10	S5755_011_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	011	0		29	10	S5755_011_0	2	2	Non-Preferred Generic	1	4	000110	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										7.00		21.00						12.00		36.00								30.00																		12.00					12.00			12.00				
S5755	011	0		29	10	S5755_011_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										40.00		100.00						45.00		113.00								90.00																		45.00					45.00			45.00				
S5755	011	0		29	10	S5755_011_0	2	4	Non-Preferred Brand	1	4	110000	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		238.00						95.00		238.00								190.00																		95.00					95.00			95.00				
S5755	011	0		29	10	S5755_011_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													611.30	29		29					611.30	29		29							29																	29				29			29			
S5755	012	0		29	10	S5755_012_0	2	4	Non-Preferred Brand	1	4	110000	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		238.00						95.00		238.00								190.00																		95.00					95.00			95.00				
S5755	012	0		29	10	S5755_012_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													454.81	29		29					454.81	29		29							29																	29				29			29			
S5755	012	0		29	10	S5755_012_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										40.00		100.00						45.00		113.00								90.00																		45.00					45.00			45.00				
S5755	012	0		29	10	S5755_012_0	2	2	Non-Preferred Generic	1	4	000110	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										7.00		21.00						12.00		36.00								30.00																		12.00					12.00			12.00				
S5755	012	0		29	10	S5755_012_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	013	0		29	10	S5755_013_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	013	0		29	10	S5755_013_0	2	2	Non-Preferred Generic	1	4	000110	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										7.00		21.00						12.00		36.00								30.00																		12.00					12.00			12.00				
S5755	013	0		29	10	S5755_013_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										40.00		100.00						45.00		113.00								90.00																		45.00					45.00			45.00				
S5755	013	0		29	10	S5755_013_0	2	4	Non-Preferred Brand	1	4	110000	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		238.00						95.00		238.00								190.00																		95.00					95.00			95.00				
S5755	013	0		29	10	S5755_013_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													565.97	29		29					565.97	29		29							29																	29				29			29			
S5755	014	0		29	10	S5755_014_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													535.56	29		29					535.56	29		29							29																	29				29			29			
S5755	014	0		29	10	S5755_014_0	2	4	Non-Preferred Brand	1	4	110000	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		238.00						95.00		238.00								190.00																		95.00					95.00			95.00				
S5755	014	0		29	10	S5755_014_0	2	2	Non-Preferred Generic	1	4	000110	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										7.00		21.00						12.00		36.00								30.00																		12.00					12.00			12.00				
S5755	014	0		29	10	S5755_014_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	014	0		29	10	S5755_014_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										40.00		100.00						45.00		113.00								90.00																		45.00					45.00			45.00				
S5755	015	0		29	10	S5755_015_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													508.39	29		29					508.39	29		29							29																	29				29			29			
S5755	015	0		29	10	S5755_015_0	2	4	Non-Preferred Brand	1	4	110000	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		238.00						95.00		238.00								190.00																		95.00					95.00			95.00				
S5755	015	0		29	10	S5755_015_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										40.00		100.00						45.00		113.00								90.00																		45.00					45.00			45.00				
S5755	015	0		29	10	S5755_015_0	2	2	Non-Preferred Generic	1	4	000110	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										7.00		21.00						12.00		36.00								30.00																		12.00					12.00			12.00				
S5755	015	0		29	10	S5755_015_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	016	0		29	10	S5755_016_0	2	4	Non-Preferred Brand	1	4	110000	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		238.00						95.00		238.00								190.00																		95.00					95.00			95.00				
S5755	016	0		29	10	S5755_016_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													573.93	29		29					573.93	29		29							29																	29				29			29			
S5755	016	0		29	10	S5755_016_0	2	2	Non-Preferred Generic	1	4	000110	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										7.00		21.00						12.00		36.00								30.00																		12.00					12.00			12.00				
S5755	016	0		29	10	S5755_016_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										40.00		100.00						45.00		113.00								90.00																		45.00					45.00			45.00				
S5755	016	0		29	10	S5755_016_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	017	0		29	10	S5755_017_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	017	0		29	10	S5755_017_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										40.00		100.00						45.00		113.00								90.00																		45.00					45.00			45.00				
S5755	017	0		29	10	S5755_017_0	2	4	Non-Preferred Brand	1	4	110000	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		238.00						95.00		238.00								190.00																		95.00					95.00			95.00				
S5755	017	0		29	10	S5755_017_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													636.26	29		29					636.26	29		29							29																	29				29			29			
S5755	017	0		29	10	S5755_017_0	2	2	Non-Preferred Generic	1	4	000110	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										7.00		21.00						12.00		36.00								30.00																		12.00					12.00			12.00				
S5755	018	0		29	10	S5755_018_0	2	2	Non-Preferred Generic	1	4	000110	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										7.00		21.00						12.00		36.00								30.00																		12.00					12.00			12.00				
S5755	018	0		29	10	S5755_018_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													833.29	29		29					833.29	29		29							29																	29				29			29			
S5755	018	0		29	10	S5755_018_0	2	4	Non-Preferred Brand	1	4	110000	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		238.00						95.00		238.00								190.00																		95.00					95.00			95.00				
S5755	018	0		29	10	S5755_018_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										40.00		100.00						45.00		113.00								90.00																		45.00					45.00			45.00				
S5755	018	0		29	10	S5755_018_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	019	0		29	10	S5755_019_0	3	1	Preferred Generic	1	4	001010	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	019	0		29	10	S5755_019_0	3	2	Non-Preferred Generic	1	4	000110	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										7.00		21.00						12.00		36.00								30.00																		12.00					12.00			12.00				
S5755	019	0		29	10	S5755_019_0	3	4	Non-Preferred Brand	1	4	110000	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		238.00						95.00		238.00								190.00																		95.00					95.00			95.00				
S5755	019	0		29	10	S5755_019_0	3	3	Preferred Brand	1	4	010001	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										40.00		100.00						45.00		113.00								90.00																		45.00					45.00			45.00				
S5755	019	0		29	10	S5755_019_0	3	5	Specialty Tier	1	4	010010	1	1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													458.84	29		29					458.84	29		29							29																	29				29			29			
S5755	020	0		29	10	S5755_020_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													447.99	29		29					447.99	29		29							29																	29				29			29			
S5755	020	0		29	10	S5755_020_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	020	0		29	10	S5755_020_0	2	2	Non-Preferred Generic	1	4	000110	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										7.00		21.00						12.00		36.00								30.00																		12.00					12.00			12.00				
S5755	020	0		29	10	S5755_020_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										40.00		100.00						45.00		113.00								90.00																		45.00					45.00			45.00				
S5755	020	0		29	10	S5755_020_0	2	4	Non-Preferred Brand	1	4	110000	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		238.00						95.00		238.00								190.00																		95.00					95.00			95.00				
S5755	021	0		29	10	S5755_021_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													764.96	29		29					764.96	29		29							29																	29				29			29			
S5755	021	0		29	10	S5755_021_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	021	0		29	10	S5755_021_0	2	2	Non-Preferred Generic	1	4	000110	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										7.00		21.00						12.00		36.00								30.00																		12.00					12.00			12.00				
S5755	021	0		29	10	S5755_021_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										40.00		100.00						45.00		113.00								90.00																		45.00					45.00			45.00				
S5755	021	0		29	10	S5755_021_0	2	4	Non-Preferred Brand	1	4	110000	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		238.00						95.00		238.00								190.00																		95.00					95.00			95.00				
S5755	022	0		29	10	S5755_022_0	2	5	Specialty Tier	1	2	010010		1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													510.34	25		25					510.34	25		25							25																	25				25			25			
S5755	022	0		29	10	S5755_022_0	2	4	Non-Preferred Brand	1	2	110000		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		285.00						95.00		285.00								257.00																		95.00					95.00			95.00				
S5755	022	0		29	10	S5755_022_0	2	3	Preferred Brand	1	2	010001		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										35.00		105.00						40.00		120.00								108.00																		40.00					40.00			40.00				
S5755	022	0		29	10	S5755_022_0	2	2	Non-Preferred Generic	1	2	000110		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										4.00		12.00						9.00		27.00								24.00																		9.00					9.00			9.00				
S5755	022	0		29	10	S5755_022_0	2	1	Preferred Generic	1	2	001010		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	023	0		29	10	S5755_023_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	023	0		29	10	S5755_023_0	2	2	Non-Preferred Generic	1	4	000110	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										7.00		21.00						12.00		36.00								30.00																		12.00					12.00			12.00				
S5755	023	0		29	10	S5755_023_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													559.02	29		29					559.02	29		29							29																	29				29			29			
S5755	023	0		29	10	S5755_023_0	2	4	Non-Preferred Brand	1	4	110000	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		238.00						95.00		238.00								190.00																		95.00					95.00			95.00				
S5755	023	0		29	10	S5755_023_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										40.00		100.00						45.00		113.00								90.00																		45.00					45.00			45.00				
S5755	024	0		29	10	S5755_024_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													486.99	29		29					486.99	29		29							29																	29				29			29			
S5755	024	0		29	10	S5755_024_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	024	0		29	10	S5755_024_0	2	2	Non-Preferred Generic	1	4	000110	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										7.00		21.00						12.00		36.00								30.00																		12.00					12.00			12.00				
S5755	024	0		29	10	S5755_024_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										40.00		100.00						45.00		113.00								90.00																		45.00					45.00			45.00				
S5755	024	0		29	10	S5755_024_0	2	4	Non-Preferred Brand	1	4	110000	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		238.00						95.00		238.00								190.00																		95.00					95.00			95.00				
S5755	025	0		29	10	S5755_025_0	2	2	Non-Preferred Generic	1	4	000110	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										7.00		21.00						12.00		36.00								30.00																		12.00					12.00			12.00				
S5755	025	0		29	10	S5755_025_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										40.00		100.00						45.00		113.00								90.00																		45.00					45.00			45.00				
S5755	025	0		29	10	S5755_025_0	2	4	Non-Preferred Brand	1	4	110000	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		238.00						95.00		238.00								190.00																		95.00					95.00			95.00				
S5755	025	0		29	10	S5755_025_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	025	0		29	10	S5755_025_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													615.08	29		29					615.08	29		29							29																	29				29			29			
S5755	026	0		29	10	S5755_026_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													463.00	29		29					463.00	29		29							29																	29				29			29			
S5755	026	0		29	10	S5755_026_0	2	2	Non-Preferred Generic	1	4	000110	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										7.00		21.00						12.00		36.00								30.00																		12.00					12.00			12.00				
S5755	026	0		29	10	S5755_026_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	026	0		29	10	S5755_026_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										40.00		100.00						45.00		113.00								90.00																		45.00					45.00			45.00				
S5755	026	0		29	10	S5755_026_0	2	4	Non-Preferred Brand	1	4	110000	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		238.00						95.00		238.00								190.00																		95.00					95.00			95.00				
S5755	027	0		29	10	S5755_027_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										40.00		100.00						45.00		113.00								90.00																		45.00					45.00			45.00				
S5755	027	0		29	10	S5755_027_0	2	4	Non-Preferred Brand	1	4	110000	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		238.00						95.00		238.00								190.00																		95.00					95.00			95.00				
S5755	027	0		29	10	S5755_027_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													556.48	29		29					556.48	29		29							29																	29				29			29			
S5755	027	0		29	10	S5755_027_0	2	2	Non-Preferred Generic	1	4	000110	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										7.00		21.00						12.00		36.00								30.00																		12.00					12.00			12.00				
S5755	027	0		29	10	S5755_027_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	028	0		29	10	S5755_028_0	2	4	Non-Preferred Brand	1	4	110000	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		238.00						95.00		238.00								190.00																		95.00					95.00			95.00				
S5755	028	0		29	10	S5755_028_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										40.00		100.00						45.00		113.00								90.00																		45.00					45.00			45.00				
S5755	028	0		29	10	S5755_028_0	2	2	Non-Preferred Generic	1	4	000110	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										7.00		21.00						12.00		36.00								30.00																		12.00					12.00			12.00				
S5755	028	0		29	10	S5755_028_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	028	0		29	10	S5755_028_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													748.38	29		29					748.38	29		29							29																	29				29			29			
S5755	029	0		29	10	S5755_029_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	029	0		29	10	S5755_029_0	2	2	Non-Preferred Generic	1	4	000110	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										7.00		21.00						12.00		36.00								30.00																		12.00					12.00			12.00				
S5755	029	0		29	10	S5755_029_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										40.00		100.00						45.00		113.00								90.00																		45.00					45.00			45.00				
S5755	029	0		29	10	S5755_029_0	2	4	Non-Preferred Brand	1	4	110000	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		238.00						95.00		238.00								190.00																		95.00					95.00			95.00				
S5755	029	0		29	10	S5755_029_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													720.64	29		29					720.64	29		29							29																	29				29			29			
S5755	030	0		29	10	S5755_030_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													502.43	29		29					502.43	29		29							29																	29				29			29			
S5755	030	0		29	10	S5755_030_0	2	4	Non-Preferred Brand	1	4	110000	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		238.00						95.00		238.00								190.00																		95.00					95.00			95.00				
S5755	030	0		29	10	S5755_030_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										40.00		100.00						45.00		113.00								90.00																		45.00					45.00			45.00				
S5755	030	0		29	10	S5755_030_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	030	0		29	10	S5755_030_0	2	2	Non-Preferred Generic	1	4	000110	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										7.00		21.00						12.00		36.00								30.00																		12.00					12.00			12.00				
S5755	031	0		29	10	S5755_031_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													614.85	29		29					614.85	29		29							29																	29				29			29			
S5755	031	0		29	10	S5755_031_0	2	4	Non-Preferred Brand	1	4	110000	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		238.00						95.00		238.00								190.00																		95.00					95.00			95.00				
S5755	031	0		29	10	S5755_031_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										40.00		100.00						45.00		113.00								90.00																		45.00					45.00			45.00				
S5755	031	0		29	10	S5755_031_0	2	2	Non-Preferred Generic	1	4	000110	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										7.00		21.00						12.00		36.00								30.00																		12.00					12.00			12.00				
S5755	031	0		29	10	S5755_031_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	032	0		29	10	S5755_032_0	2	4	Non-Preferred Brand	1	4	110000	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		238.00						95.00		238.00								190.00																		95.00					95.00			95.00				
S5755	032	0		29	10	S5755_032_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	032	0		29	10	S5755_032_0	2	2	Non-Preferred Generic	1	4	000110	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										7.00		21.00						12.00		36.00								30.00																		12.00					12.00			12.00				
S5755	032	0		29	10	S5755_032_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													451.99	29		29					451.99	29		29							29																	29				29			29			
S5755	032	0		29	10	S5755_032_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										40.00		100.00						45.00		113.00								90.00																		45.00					45.00			45.00				
S5755	033	0		29	10	S5755_033_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													514.04	29		29					514.04	29		29							29																	29				29			29			
S5755	033	0		29	10	S5755_033_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										40.00		100.00						45.00		113.00								90.00																		45.00					45.00			45.00				
S5755	033	0		29	10	S5755_033_0	2	2	Non-Preferred Generic	1	4	000110	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										7.00		21.00						12.00		36.00								30.00																		12.00					12.00			12.00				
S5755	033	0		29	10	S5755_033_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	033	0		29	10	S5755_033_0	2	4	Non-Preferred Brand	1	4	110000	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		238.00						95.00		238.00								190.00																		95.00					95.00			95.00				
S5755	034	0		29	10	S5755_034_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													189.79	29		29					189.79	29		29							29																	29				29			29			
S5755	034	0		29	10	S5755_034_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										40.00		100.00						45.00		113.00								90.00																		45.00					45.00			45.00				
S5755	034	0		29	10	S5755_034_0	2	2	Non-Preferred Generic	1	4	000110	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										7.00		21.00						12.00		36.00								30.00																		12.00					12.00			12.00				
S5755	034	0		29	10	S5755_034_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	034	0		29	10	S5755_034_0	2	4	Non-Preferred Brand	1	4	110000	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		238.00						95.00		238.00								190.00																		95.00					95.00			95.00				
S5755	035	0		29	10	S5755_035_0	2	4	Non-Preferred Brand	1	4	110000	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		238.00						95.00		238.00								190.00																		95.00					95.00			95.00				
S5755	035	0		29	10	S5755_035_0	2	2	Non-Preferred Generic	1	4	000110	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										7.00		21.00						12.00		36.00								30.00																		12.00					12.00			12.00				
S5755	035	0		29	10	S5755_035_0	2	3	Preferred Brand	1	4	010001	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										40.00		100.00						45.00		113.00								90.00																		45.00					45.00			45.00				
S5755	035	0		29	10	S5755_035_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	035	0		29	10	S5755_035_0	2	5	Specialty Tier	1	4	010010	1	1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													590.86	29		29					590.86	29		29							29																	29				29			29			
S5755	038	0		29	10	S5755_038_0	2	4	Non-Preferred Brand	1	2	110000		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		285.00						95.00		285.00								257.00																		95.00					95.00			95.00				
S5755	038	0		29	10	S5755_038_0	2	3	Preferred Brand	1	2	010001		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										40.00		120.00						45.00		135.00								122.00																		45.00					45.00			45.00				
S5755	038	0		29	10	S5755_038_0	2	2	Non-Preferred Generic	1	2	000110		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										4.00		12.00						9.00		27.00								24.00																		9.00					9.00			9.00				
S5755	038	0		29	10	S5755_038_0	2	5	Specialty Tier	1	2	010010		1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													385.72	25		25					385.72	25		25							25																	25				25			25			
S5755	038	0		29	10	S5755_038_0	2	1	Preferred Generic	1	2	001010		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	039	0		29	10	S5755_039_0	2	3	Preferred Brand	1	2	010001		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										25.00		75.00						30.00		90.00								81.00																		30.00					30.00			30.00				
S5755	039	0		29	10	S5755_039_0	2	4	Non-Preferred Brand	1	2	110000		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		285.00						95.00		285.00								257.00																		95.00					95.00			95.00				
S5755	039	0		29	10	S5755_039_0	2	5	Specialty Tier	1	2	010010		1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													460.68	25		25					460.68	25		25							25																	25				25			25			
S5755	039	0		29	10	S5755_039_0	2	2	Non-Preferred Generic	1	2	000110		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										4.00		12.00						9.00		27.00								24.00																		9.00					9.00			9.00				
S5755	039	0		29	10	S5755_039_0	2	1	Preferred Generic	1	2	001010		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	073	0		29	10	S5755_073_0	2	1	Preferred Generic	1	2	001010		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	073	0		29	10	S5755_073_0	2	2	Non-Preferred Generic	1	2	000110		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										4.00		12.00						9.00		27.00								24.00																		9.00					9.00			9.00				
S5755	073	0		29	10	S5755_073_0	2	5	Specialty Tier	1	2	010010		1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													518.46	25		25					518.46	25		25							25																	25				25			25			
S5755	073	0		29	10	S5755_073_0	2	4	Non-Preferred Brand	1	2	110000		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		285.00						95.00		285.00								257.00																		95.00					95.00			95.00				
S5755	073	0		29	10	S5755_073_0	2	3	Preferred Brand	1	2	010001		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										36.00		108.00						41.00		123.00								111.00																		41.00					41.00			41.00				
S5755	074	0		29	10	S5755_074_0	2	3	Preferred Brand	1	2	010001		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										40.00		120.00						45.00		135.00								122.00																		45.00					45.00			45.00				
S5755	074	0		29	10	S5755_074_0	2	4	Non-Preferred Brand	1	2	110000		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		285.00						95.00		285.00								257.00																		95.00					95.00			95.00				
S5755	074	0		29	10	S5755_074_0	2	5	Specialty Tier	1	2	010010		1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													537.16	25		25					537.16	25		25							25																	25				25			25			
S5755	074	0		29	10	S5755_074_0	2	2	Non-Preferred Generic	1	2	000110		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										4.00		12.00						9.00		27.00								24.00																		9.00					9.00			9.00				
S5755	074	0		29	10	S5755_074_0	2	1	Preferred Generic	1	2	001010		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	075	0		29	10	S5755_075_0	2	5	Specialty Tier	1	2	010010		1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													537.06	25		25					537.06	25		25							25																	25				25			25			
S5755	075	0		29	10	S5755_075_0	2	4	Non-Preferred Brand	1	2	110000		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		285.00						95.00		285.00								257.00																		95.00					95.00			95.00				
S5755	075	0		29	10	S5755_075_0	2	2	Non-Preferred Generic	1	2	000110		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										4.00		12.00						9.00		27.00								24.00																		9.00					9.00			9.00				
S5755	075	0		29	10	S5755_075_0	2	3	Preferred Brand	1	2	010001		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										40.00		120.00						45.00		135.00								122.00																		45.00					45.00			45.00				
S5755	075	0		29	10	S5755_075_0	2	1	Preferred Generic	1	2	001010		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	076	0		29	10	S5755_076_0	2	5	Specialty Tier	1	2	010010		1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													539.91	25		25					539.91	25		25							25																	25				25			25			
S5755	076	0		29	10	S5755_076_0	2	4	Non-Preferred Brand	1	2	110000		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		285.00						95.00		285.00								257.00																		95.00					95.00			95.00				
S5755	076	0		29	10	S5755_076_0	2	1	Preferred Generic	1	2	001010		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	076	0		29	10	S5755_076_0	2	2	Non-Preferred Generic	1	2	000110		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										4.00		12.00						9.00		27.00								24.00																		9.00					9.00			9.00				
S5755	076	0		29	10	S5755_076_0	2	3	Preferred Brand	1	2	010001		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										40.00		120.00						45.00		135.00								122.00																		45.00					45.00			45.00				
S5755	077	0		29	10	S5755_077_0	2	5	Specialty Tier	1	2	010010		1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													512.65	25		25					512.65	25		25							25																	25				25			25			
S5755	077	0		29	10	S5755_077_0	2	4	Non-Preferred Brand	1	2	110000		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		285.00						95.00		285.00								257.00																		95.00					95.00			95.00				
S5755	077	0		29	10	S5755_077_0	2	2	Non-Preferred Generic	1	2	000110		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										4.00		12.00						9.00		27.00								24.00																		9.00					9.00			9.00				
S5755	077	0		29	10	S5755_077_0	2	1	Preferred Generic	1	2	001010		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	077	0		29	10	S5755_077_0	2	3	Preferred Brand	1	2	010001		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										35.00		105.00						40.00		120.00								108.00																		40.00					40.00			40.00				
S5755	078	0		29	10	S5755_078_0	2	2	Non-Preferred Generic	1	2	000110		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										4.00		12.00						9.00		27.00								24.00																		9.00					9.00			9.00				
S5755	078	0		29	10	S5755_078_0	2	3	Preferred Brand	1	2	010001		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										34.00		102.00						39.00		117.00								106.00																		39.00					39.00			39.00				
S5755	078	0		29	10	S5755_078_0	2	5	Specialty Tier	1	2	010010		1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													508.30	25		25					508.30	25		25							25																	25				25			25			
S5755	078	0		29	10	S5755_078_0	2	4	Non-Preferred Brand	1	2	110000		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		285.00						95.00		285.00								257.00																		95.00					95.00			95.00				
S5755	078	0		29	10	S5755_078_0	2	1	Preferred Generic	1	2	001010		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	079	0		29	10	S5755_079_0	2	1	Preferred Generic	1	2	001010		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	079	0		29	10	S5755_079_0	2	2	Non-Preferred Generic	1	2	000110		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										4.00		12.00						9.00		27.00								24.00																		9.00					9.00			9.00				
S5755	079	0		29	10	S5755_079_0	2	3	Preferred Brand	1	2	010001		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										37.00		111.00						42.00		126.00								114.00																		42.00					42.00			42.00				
S5755	079	0		29	10	S5755_079_0	2	4	Non-Preferred Brand	1	2	110000		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		285.00						95.00		285.00								257.00																		95.00					95.00			95.00				
S5755	079	0		29	10	S5755_079_0	2	5	Specialty Tier	1	2	010010		1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													519.70	25		25					519.70	25		25							25																	25				25			25			
S5755	080	0		29	10	S5755_080_0	2	4	Non-Preferred Brand	1	2	110000		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		285.00						95.00		285.00								257.00																		95.00					95.00			95.00				
S5755	080	0		29	10	S5755_080_0	2	3	Preferred Brand	1	2	010001		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										36.00		108.00						41.00		123.00								111.00																		41.00					41.00			41.00				
S5755	080	0		29	10	S5755_080_0	2	2	Non-Preferred Generic	1	2	000110		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										4.00		12.00						9.00		27.00								24.00																		9.00					9.00			9.00				
S5755	080	0		29	10	S5755_080_0	2	1	Preferred Generic	1	2	001010		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	080	0		29	10	S5755_080_0	2	5	Specialty Tier	1	2	010010		1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													513.89	25		25					513.89	25		25							25																	25				25			25			
S5755	081	0		29	10	S5755_081_0	2	1	Preferred Generic	1	2	001010		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	081	0		29	10	S5755_081_0	2	2	Non-Preferred Generic	1	2	000110		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										4.00		12.00						9.00		27.00								24.00																		9.00					9.00			9.00				
S5755	081	0		29	10	S5755_081_0	2	3	Preferred Brand	1	2	010001		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										34.00		102.00						39.00		117.00								106.00																		39.00					39.00			39.00				
S5755	081	0		29	10	S5755_081_0	2	4	Non-Preferred Brand	1	2	110000		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		285.00						95.00		285.00								257.00																		95.00					95.00			95.00				
S5755	081	0		29	10	S5755_081_0	2	5	Specialty Tier	1	2	010010		1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													503.86	25		25					503.86	25		25							25																	25				25			25			
S5755	082	0		29	10	S5755_082_0	2	5	Specialty Tier	1	2	010010		1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													530.30	25		25					530.30	25		25							25																	25				25			25			
S5755	082	0		29	10	S5755_082_0	2	4	Non-Preferred Brand	1	2	110000		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		285.00						95.00		285.00								257.00																		95.00					95.00			95.00				
S5755	082	0		29	10	S5755_082_0	2	3	Preferred Brand	1	2	010001		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										40.00		120.00						45.00		135.00								122.00																		45.00					45.00			45.00				
S5755	082	0		29	10	S5755_082_0	2	1	Preferred Generic	1	2	001010		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	082	0		29	10	S5755_082_0	2	2	Non-Preferred Generic	1	2	000110		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										4.00		12.00						9.00		27.00								24.00																		9.00					9.00			9.00				
S5755	083	0		29	10	S5755_083_0	2	5	Specialty Tier	1	2	010010		1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													493.19	25		25					493.19	25		25							25																	25				25			25			
S5755	083	0		29	10	S5755_083_0	2	4	Non-Preferred Brand	1	2	110000		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		285.00						95.00		285.00								257.00																		95.00					95.00			95.00				
S5755	083	0		29	10	S5755_083_0	2	3	Preferred Brand	1	2	010001		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										30.00		90.00						35.00		105.00								95.00																		35.00					35.00			35.00				
S5755	083	0		29	10	S5755_083_0	2	1	Preferred Generic	1	2	001010		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	083	0		29	10	S5755_083_0	2	2	Non-Preferred Generic	1	2	000110		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										4.00		12.00						9.00		27.00								24.00																		9.00					9.00			9.00				
S5755	084	0		29	10	S5755_084_0	2	2	Non-Preferred Generic	1	2	000110		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										4.00		12.00						9.00		27.00								24.00																		9.00					9.00			9.00				
S5755	084	0		29	10	S5755_084_0	2	3	Preferred Brand	1	2	010001		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										38.00		114.00						43.00		129.00								117.00																		43.00					43.00			43.00				
S5755	084	0		29	10	S5755_084_0	2	4	Non-Preferred Brand	1	2	110000		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		285.00						95.00		285.00								257.00																		95.00					95.00			95.00				
S5755	084	0		29	10	S5755_084_0	2	1	Preferred Generic	1	2	001010		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	084	0		29	10	S5755_084_0	2	5	Specialty Tier	1	2	010010		1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													525.14	25		25					525.14	25		25							25																	25				25			25			
S5755	085	0		29	10	S5755_085_0	2	5	Specialty Tier	1	2	010010		1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													511.38	25		25					511.38	25		25							25																	25				25			25			
S5755	085	0		29	10	S5755_085_0	2	4	Non-Preferred Brand	1	2	110000		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		285.00						95.00		285.00								257.00																		95.00					95.00			95.00				
S5755	085	0		29	10	S5755_085_0	2	3	Preferred Brand	1	2	010001		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										35.00		105.00						40.00		120.00								108.00																		40.00					40.00			40.00				
S5755	085	0		29	10	S5755_085_0	2	1	Preferred Generic	1	2	001010		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	085	0		29	10	S5755_085_0	2	2	Non-Preferred Generic	1	2	000110		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										4.00		12.00						9.00		27.00								24.00																		9.00					9.00			9.00				
S5755	086	0		29	10	S5755_086_0	2	3	Preferred Brand	1	2	010001		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										31.00		93.00						36.00		108.00								98.00																		36.00					36.00			36.00				
S5755	086	0		29	10	S5755_086_0	2	2	Non-Preferred Generic	1	2	000110		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										4.00		12.00						9.00		27.00								24.00																		9.00					9.00			9.00				
S5755	086	0		29	10	S5755_086_0	2	4	Non-Preferred Brand	1	2	110000		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		285.00						95.00		285.00								257.00																		95.00					95.00			95.00				
S5755	086	0		29	10	S5755_086_0	2	1	Preferred Generic	1	2	001010		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	086	0		29	10	S5755_086_0	2	5	Specialty Tier	1	2	010010		1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													499.52	25		25					499.52	25		25							25																	25				25			25			
S5755	087	0		29	10	S5755_087_0	2	5	Specialty Tier	1	2	010010		1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													526.30	25		25					526.30	25		25							25																	25				25			25			
S5755	087	0		29	10	S5755_087_0	2	4	Non-Preferred Brand	1	2	110000		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		285.00						95.00		285.00								257.00																		95.00					95.00			95.00				
S5755	087	0		29	10	S5755_087_0	2	3	Preferred Brand	1	2	010001		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										38.00		114.00						43.00		129.00								117.00																		43.00					43.00			43.00				
S5755	087	0		29	10	S5755_087_0	2	2	Non-Preferred Generic	1	2	000110		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										4.00		12.00						9.00		27.00								24.00																		9.00					9.00			9.00				
S5755	087	0		29	10	S5755_087_0	2	1	Preferred Generic	1	2	001010		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	088	0		29	10	S5755_088_0	2	4	Non-Preferred Brand	1	2	110000		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		285.00						95.00		285.00								257.00																		95.00					95.00			95.00				
S5755	088	0		29	10	S5755_088_0	2	2	Non-Preferred Generic	1	2	000110		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										4.00		12.00						9.00		27.00								24.00																		9.00					9.00			9.00				
S5755	088	0		29	10	S5755_088_0	2	3	Preferred Brand	1	2	010001		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										35.00		105.00						40.00		120.00								108.00																		40.00					40.00			40.00				
S5755	088	0		29	10	S5755_088_0	2	5	Specialty Tier	1	2	010010		1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													510.78	25		25					510.78	25		25							25																	25				25			25			
S5755	088	0		29	10	S5755_088_0	2	1	Preferred Generic	1	2	001010		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	089	0		29	10	S5755_089_0	2	3	Preferred Brand	1	2	010001		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										33.00		99.00						38.00		114.00								103.00																		38.00					38.00			38.00				
S5755	089	0		29	10	S5755_089_0	2	4	Non-Preferred Brand	1	2	110000		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		285.00						95.00		285.00								257.00																		95.00					95.00			95.00				
S5755	089	0		29	10	S5755_089_0	2	5	Specialty Tier	1	2	010010		1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													515.76	25		25					515.76	25		25							25																	25				25			25			
S5755	089	0		29	10	S5755_089_0	2	1	Preferred Generic	1	2	001010		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	089	0		29	10	S5755_089_0	2	2	Non-Preferred Generic	1	2	000110		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										4.00		12.00						9.00		27.00								24.00																		9.00					9.00			9.00				
S5755	091	0		29	10	S5755_091_0	2	1	Preferred Generic	1	2	001010		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	091	0		29	10	S5755_091_0	2	2	Non-Preferred Generic	1	2	000110		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										4.00		12.00						9.00		27.00								24.00																		9.00					9.00			9.00				
S5755	091	0		29	10	S5755_091_0	2	5	Specialty Tier	1	2	010010		1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													491.11	25		25					491.11	25		25							25																	25				25			25			
S5755	091	0		29	10	S5755_091_0	2	4	Non-Preferred Brand	1	2	110000		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		285.00						95.00		285.00								257.00																		95.00					95.00			95.00				
S5755	091	0		29	10	S5755_091_0	2	3	Preferred Brand	1	2	010001		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										30.00		90.00						35.00		105.00								95.00																		35.00					35.00			35.00				
S5755	092	0		29	10	S5755_092_0	2	2	Non-Preferred Generic	1	2	000110		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										4.00		12.00						9.00		27.00								24.00																		9.00					9.00			9.00				
S5755	092	0		29	10	S5755_092_0	2	4	Non-Preferred Brand	1	2	110000		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		285.00						95.00		285.00								257.00																		95.00					95.00			95.00				
S5755	092	0		29	10	S5755_092_0	2	5	Specialty Tier	1	2	010010		1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													495.19	25		25					495.19	25		25							25																	25				25			25			
S5755	092	0		29	10	S5755_092_0	2	3	Preferred Brand	1	2	010001		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										32.00		96.00						37.00		111.00								100.00																		37.00					37.00			37.00				
S5755	092	0		29	10	S5755_092_0	2	1	Preferred Generic	1	2	001010		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	093	0		29	10	S5755_093_0	2	2	Non-Preferred Generic	1	2	000110		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										4.00		12.00						9.00		27.00								24.00																		9.00					9.00			9.00				
S5755	093	0		29	10	S5755_093_0	2	5	Specialty Tier	1	2	010010		1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													518.24	25		25					518.24	25		25							25																	25				25			25			
S5755	093	0		29	10	S5755_093_0	2	1	Preferred Generic	1	2	001010		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	093	0		29	10	S5755_093_0	2	3	Preferred Brand	1	2	010001		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										38.00		114.00						43.00		129.00								117.00																		43.00					43.00			43.00				
S5755	093	0		29	10	S5755_093_0	2	4	Non-Preferred Brand	1	2	110000		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		285.00						95.00		285.00								257.00																		95.00					95.00			95.00				
S5755	094	0		29	10	S5755_094_0	2	5	Specialty Tier	1	2	010010		1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													510.29	25		25					510.29	25		25							25																	25				25			25			
S5755	094	0		29	10	S5755_094_0	2	4	Non-Preferred Brand	1	2	110000		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		285.00						95.00		285.00								257.00																		95.00					95.00			95.00				
S5755	094	0		29	10	S5755_094_0	2	3	Preferred Brand	1	2	010001		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										35.00		105.00						40.00		120.00								108.00																		40.00					40.00			40.00				
S5755	094	0		29	10	S5755_094_0	2	2	Non-Preferred Generic	1	2	000110		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										4.00		12.00						9.00		27.00								24.00																		9.00					9.00			9.00				
S5755	094	0		29	10	S5755_094_0	2	1	Preferred Generic	1	2	001010		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	095	0		29	10	S5755_095_0	2	1	Preferred Generic	1	2	001010		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	095	0		29	10	S5755_095_0	2	2	Non-Preferred Generic	1	2	000110		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										4.00		12.00						9.00		27.00								24.00																		9.00					9.00			9.00				
S5755	095	0		29	10	S5755_095_0	2	5	Specialty Tier	1	2	010010		1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													522.51	25		25					522.51	25		25							25																	25				25			25			
S5755	095	0		29	10	S5755_095_0	2	4	Non-Preferred Brand	1	2	110000		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		285.00						95.00		285.00								257.00																		95.00					95.00			95.00				
S5755	095	0		29	10	S5755_095_0	2	3	Preferred Brand	1	2	010001		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										37.00		111.00						42.00		126.00								114.00																		42.00					42.00			42.00				
S5755	096	0		29	10	S5755_096_0	2	1	Preferred Generic	1	2	001010		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	096	0		29	10	S5755_096_0	2	2	Non-Preferred Generic	1	2	000110		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										4.00		12.00						9.00		27.00								24.00																		9.00					9.00			9.00				
S5755	096	0		29	10	S5755_096_0	2	3	Preferred Brand	1	2	010001		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										40.00		120.00						45.00		135.00								122.00																		45.00					45.00			45.00				
S5755	096	0		29	10	S5755_096_0	2	4	Non-Preferred Brand	1	2	110000		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		285.00						95.00		285.00								257.00																		95.00					95.00			95.00				
S5755	096	0		29	10	S5755_096_0	2	5	Specialty Tier	1	2	010010		1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													540.87	25		25					540.87	25		25							25																	25				25			25			
S5755	097	0		29	10	S5755_097_0	2	1	Preferred Generic	1	2	001010		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	097	0		29	10	S5755_097_0	2	3	Preferred Brand	1	2	010001		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										36.00		108.00						41.00		123.00								111.00																		41.00					41.00			41.00				
S5755	097	0		29	10	S5755_097_0	2	4	Non-Preferred Brand	1	2	110000		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		285.00						95.00		285.00								257.00																		95.00					95.00			95.00				
S5755	097	0		29	10	S5755_097_0	2	2	Non-Preferred Generic	1	2	000110		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										4.00		12.00						9.00		27.00								24.00																		9.00					9.00			9.00				
S5755	097	0		29	10	S5755_097_0	2	5	Specialty Tier	1	2	010010		1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													513.51	25		25					513.51	25		25							25																	25				25			25			
S5755	098	0		29	10	S5755_098_0	2	1	Preferred Generic	1	2	001010		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	098	0		29	10	S5755_098_0	2	4	Non-Preferred Brand	1	2	110000		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		285.00						95.00		285.00								257.00																		95.00					95.00			95.00				
S5755	098	0		29	10	S5755_098_0	2	3	Preferred Brand	1	2	010001		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										36.00		108.00						41.00		123.00								111.00																		41.00					41.00			41.00				
S5755	098	0		29	10	S5755_098_0	2	2	Non-Preferred Generic	1	2	000110		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										4.00		12.00						9.00		27.00								24.00																		9.00					9.00			9.00				
S5755	098	0		29	10	S5755_098_0	2	5	Specialty Tier	1	2	010010		1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													534.35	25		25					534.35	25		25							25																	25				25			25			
S5755	099	0		29	10	S5755_099_0	2	4	Non-Preferred Brand	1	2	110000		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		285.00						95.00		285.00								257.00																		95.00					95.00			95.00				
S5755	099	0		29	10	S5755_099_0	2	3	Preferred Brand	1	2	010001		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										31.00		93.00						36.00		108.00								98.00																		36.00					36.00			36.00				
S5755	099	0		29	10	S5755_099_0	2	2	Non-Preferred Generic	1	2	000110		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										4.00		12.00						9.00		27.00								24.00																		9.00					9.00			9.00				
S5755	099	0		29	10	S5755_099_0	2	5	Specialty Tier	1	2	010010		1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													492.07	25		25					492.07	25		25							25																	25				25			25			
S5755	099	0		29	10	S5755_099_0	2	1	Preferred Generic	1	2	001010		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	100	0		29	10	S5755_100_0	2	1	Preferred Generic	1	2	001010		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	100	0		29	10	S5755_100_0	2	2	Non-Preferred Generic	1	2	000110		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										4.00		12.00						9.00		27.00								24.00																		9.00					9.00			9.00				
S5755	100	0		29	10	S5755_100_0	2	3	Preferred Brand	1	2	010001		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										37.00		111.00						42.00		126.00								114.00																		42.00					42.00			42.00				
S5755	100	0		29	10	S5755_100_0	2	4	Non-Preferred Brand	1	2	110000		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		285.00						95.00		285.00								257.00																		95.00					95.00			95.00				
S5755	100	0		29	10	S5755_100_0	2	5	Specialty Tier	1	2	010010		1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													540.08	25		25					540.08	25		25							25																	25				25			25			
S5755	101	0		29	10	S5755_101_0	2	5	Specialty Tier	1	2	010010		1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													516.52	25		25					516.52	25		25							25																	25				25			25			
S5755	101	0		29	10	S5755_101_0	2	4	Non-Preferred Brand	1	2	110000		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		285.00						95.00		285.00								257.00																		95.00					95.00			95.00				
S5755	101	0		29	10	S5755_101_0	2	3	Preferred Brand	1	2	010001		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										35.00		105.00						40.00		120.00								108.00																		40.00					40.00			40.00				
S5755	101	0		29	10	S5755_101_0	2	1	Preferred Generic	1	2	001010		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	101	0		29	10	S5755_101_0	2	2	Non-Preferred Generic	1	2	000110		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										4.00		12.00						9.00		27.00								24.00																		9.00					9.00			9.00				
S5755	102	0		29	10	S5755_102_0	2	4	Non-Preferred Brand	1	2	110000		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		285.00						95.00		285.00								257.00																		95.00					95.00			95.00				
S5755	102	0		29	10	S5755_102_0	2	3	Preferred Brand	1	2	010001		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										38.00		114.00						43.00		129.00								117.00																		43.00					43.00			43.00				
S5755	102	0		29	10	S5755_102_0	2	2	Non-Preferred Generic	1	2	000110		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										4.00		12.00						9.00		27.00								24.00																		9.00					9.00			9.00				
S5755	102	0		29	10	S5755_102_0	2	1	Preferred Generic	1	2	001010		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	102	0		29	10	S5755_102_0	2	5	Specialty Tier	1	2	010010		1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													531.29	25		25					531.29	25		25							25																	25				25			25			
S5755	103	0		29	10	S5755_103_0	2	5	Specialty Tier	1	2	010010		1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													541.55	25		25					541.55	25		25							25																	25				25			25			
S5755	103	0		29	10	S5755_103_0	2	4	Non-Preferred Brand	1	2	110000		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		285.00						95.00		285.00								257.00																		95.00					95.00			95.00				
S5755	103	0		29	10	S5755_103_0	2	3	Preferred Brand	1	2	010001		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										37.00		111.00						42.00		126.00								114.00																		42.00					42.00			42.00				
S5755	103	0		29	10	S5755_103_0	2	1	Preferred Generic	1	2	001010		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	103	0		29	10	S5755_103_0	2	2	Non-Preferred Generic	1	2	000110		2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										4.00		12.00						9.00		27.00								24.00																		9.00					9.00			9.00				
S5755	106	0		29	10	S5755_106_0	3	4	Non-Preferred Brand	1	4	110000	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										95.00		238.00						95.00		238.00								190.00																		95.00					95.00			95.00				
S5755	106	0		29	10	S5755_106_0	3	3	Preferred Brand	1	4	010001	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										40.00		100.00						45.00		113.00								90.00																		45.00					45.00			45.00				
S5755	106	0		29	10	S5755_106_0	3	2	Non-Preferred Generic	1	4	000110	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										7.00		21.00						12.00		36.00								30.00																		12.00					12.00			12.00				
S5755	106	0		29	10	S5755_106_0	3	1	Preferred Generic	1	4	001010	1	2	100010110110001000000101				34		90	34		90	1			90							34		34		34	14										1.00		3.00						6.00		18.00								0.00																		6.00					6.00			6.00				
S5755	106	0		29	10	S5755_106_0	3	5	Specialty Tier	1	4	010010	1	1	100010110110001000000101				34		90	34		90	1			90							34		34		34	14													567.88	29		29					567.88	29		29							29																	29				29			29			
S5766	002	0		29	10	S5766_002_0	6	1	Preferred Generic	1	3	001000		2	011100000010000000000100	34	60	90							2										34		34					5.00	10.00	12.50																																										5.00					5.00							
S5766	002	0		29	10	S5766_002_0	6	2	Non-Preferred Generic	1	3	000100		2	011100000010000000000100	34	60	90							2										34		34					16.00	32.00	40.00																																										16.00					16.00							
S5766	002	0		29	10	S5766_002_0	6	3	Preferred Brand	1	3	000001		1	111100000010000000000001	34	60	90							2										34				34	14					57.85	20	20	20																																								20							20			
S5766	002	0		29	10	S5766_002_0	6	5	Specialty Tier	1	3	010010		1	111100000010000000000101	34	60	90							2										34		34		34	14					554.53	25	25	25																																								25				25			25			
S5766	002	0		29	10	S5766_002_0	6	4	Non-Preferred Brand	1	3	100000		1	111100000010000000000001	34	60	90							2										34				34	14					87.81	37	37	37																																								37							37			
S5766	003	0		29	10	S5766_003_0	6	4	Non-Preferred Brand	1	4	100000	1	1	111100000010000000000001	34	60	90							2										34				34	14					95.87	37	37	37																																								37							37			
S5766	003	0		29	10	S5766_003_0	6	5	Specialty Tier	1	4	010010	1	1	111100000010000000000101	34	60	90							2										34		34		34	14					706.77	33	33	33																																								33				33			33			
S5766	003	0		29	10	S5766_003_0	6	2	Non-Preferred Generic	3	4	000100	1	2	011100000010000000000100	34	60	90							2										34		34					16.00	32.00	40.00																																										16.00					16.00					1		
S5766	003	0		29	10	S5766_003_0	6	3	Preferred Brand	1	4	000001	1	1	111100000010000000000001	34	60	90							2										34				34	14					62.89	20	20	20																																								20							20			
S5766	003	0		29	10	S5766_003_0	6	2	Non-Preferred Generic	1	4	000100	1	2	011100000010000000000100	34	60	90							2										34		34					16.00	32.00	40.00																																										16.00					16.00							
S5766	003	0		29	10	S5766_003_0	6	1	Preferred Generic	1	4	001000	1	2	011100000010000000000100	34	60	90							2										34		34					5.00	10.00	12.50																																										5.00					5.00							
S5766	003	0		29	10	S5766_003_0	6	1	Preferred Generic	3	4	001000	1	2	011100000010000000000100	34	60	90							2										34		34					5.00	10.00	12.50																																										5.00					5.00					1		
S5768	005	0		29	10	S5768_005_0	2	2	Preferred Brand	1	2	000001		1	110100000010101000000001	30		90							2	30		90							30				31	14					40.78	25		25																					25		25																	25							25			
S5768	005	0		29	10	S5768_005_0	2	1	Preferred Generic	1	2	001000		2	010100000010101000000100	30		90							2	30		90							30		31					1.00		3.00																						1.00		3.00																		1.00					1.00							
S5768	005	0		29	10	S5768_005_0	2	3	Non-Preferred Brand	1	2	100100		1	110100000010101000000101	30		90							2	30		90							30		31		31	14					63.67	46		46																					46		46																	46				46			46			
S5768	007	0		29	10	S5768_007_0	2	3	Non-Preferred Brand	1	2	100100		1	110100000010101000000101	30		90							2	30		90							30		31		31	14					69.43	41		41																					41		41																	41				41			41			
S5768	007	0		29	10	S5768_007_0	2	1	Preferred Generic	1	2	001000		2	010100000010101000000100	30		90							2	30		90							30		31					1.00		3.00																						1.00		3.00																		1.00					1.00							
S5768	007	0		29	10	S5768_007_0	2	2	Preferred Brand	1	2	000001		1	110100000010101000000001	30		90							2	30		90							30				31	14					46.10	25		25																					25		25																	25							25			
S5768	008	0		29	10	S5768_008_0	2	2	Preferred Brand	1	2	000001		1	110100000010101000000001	30		90							2	30		90							30				31	14					42.62	25		25																					25		25																	25							25			
S5768	008	0		29	10	S5768_008_0	2	3	Non-Preferred Brand	1	2	100100		1	110100000010101000000101	30		90							2	30		90							30		31		31	14					64.81	43		43																					43		43																	43				43			43			
S5768	008	0		29	10	S5768_008_0	2	1	Preferred Generic	1	2	001000		2	010100000010101000000100	30		90							2	30		90							30		31					1.00		3.00																						1.00		3.00																		1.00					1.00							
S5768	009	0		29	10	S5768_009_0	2	1	Preferred Generic	1	2	001000		2	010100000010101000000100	30		90							2	30		90							30		31					1.00		3.00																						1.00		3.00																		1.00					1.00							
S5768	009	0		29	10	S5768_009_0	2	2	Preferred Brand	1	2	000001		1	110100000010101000000001	30		90							2	30		90							30				31	14					44.43	25		25																					25		25																	25							25			
S5768	009	0		29	10	S5768_009_0	2	3	Non-Preferred Brand	1	2	100100		1	110100000010101000000101	30		90							2	30		90							30		31		31	14					68.58	45		45																					45		45																	45				45			45			
S5768	010	0		29	10	S5768_010_0	2	2	Preferred Brand	1	2	000001		1	110100000010101000000001	30		90							2	30		90							30				31	14					40.80	25		25																					25		25																	25							25			
S5768	010	0		29	10	S5768_010_0	2	1	Preferred Generic	1	2	001000		2	010100000010101000000100	30		90							2	30		90							30		31					1.00		3.00																						1.00		3.00																		1.00					1.00							
S5768	010	0		29	10	S5768_010_0	2	3	Non-Preferred Brand	1	2	100100		1	110100000010101000000101	30		90							2	30		90							30		31		31	14					61.19	44		44																					44		44																	44				44			44			
S5768	012	0		29	10	S5768_012_0	2	3	Non-Preferred Brand	1	2	100100		1	110100000010101000000101	30		90							2	30		90							30		31		31	14					61.39	43		43																					43		43																	43				43			43			
S5768	012	0		29	10	S5768_012_0	2	1	Preferred Generic	1	2	001000		2	010100000010101000000100	30		90							2	30		90							30		31					1.00		3.00																						1.00		3.00																		1.00					1.00							
S5768	012	0		29	10	S5768_012_0	2	2	Preferred Brand	1	2	000001		1	110100000010101000000001	30		90							2	30		90							30				31	14					42.26	25		25																					25		25																	25							25			
S5768	015	0		29	10	S5768_015_0	2	2	Preferred Brand	1	2	000001		1	110100000010101000000001	30		90							2	30		90							30				31	14					39.11	25		25																					25		25																	25							25			
S5768	015	0		29	10	S5768_015_0	2	3	Non-Preferred Brand	1	2	100100		1	110100000010101000000101	30		90							2	30		90							30		31		31	14					60.05	45		45																					45		45																	45				45			45			
S5768	015	0		29	10	S5768_015_0	2	1	Preferred Generic	1	2	001000		2	010100000010101000000100	30		90							2	30		90							30		31					1.00		3.00																						1.00		3.00																		1.00					1.00							
S5768	016	0		29	10	S5768_016_0	2	2	Preferred Brand	1	2	000001		1	110100000010101000000001	30		90							2	30		90							30				31	14					42.57	25		25																					25		25																	25							25			
S5768	016	0		29	10	S5768_016_0	2	1	Preferred Generic	1	2	001000		2	010100000010101000000100	30		90							2	30		90							30		31					1.00		3.00																						1.00		3.00																		1.00					1.00							
S5768	016	0		29	10	S5768_016_0	2	3	Non-Preferred Brand	1	2	100100		1	110100000010101000000101	30		90							2	30		90							30		31		31	14					74.55	45		45																					45		45																	45				45			45			
S5768	017	0		29	10	S5768_017_0	2	1	Preferred Generic	1	2	001000		2	010100000010101000000100	30		90							2	30		90							30		31					1.00		3.00																						1.00		3.00																		1.00					1.00							
S5768	017	0		29	10	S5768_017_0	2	3	Non-Preferred Brand	1	2	100100		1	110100000010101000000101	30		90							2	30		90							30		31		31	14					59.59	49		49																					49		49																	49				49			49			
S5768	017	0		29	10	S5768_017_0	2	2	Preferred Brand	1	2	000001		1	110100000010101000000001	30		90							2	30		90							30				31	14					42.48	25		25																					25		25																	25							25			
S5768	018	0		29	10	S5768_018_0	2	1	Preferred Generic	1	2	001000		2	010100000010101000000100	30		90							2	30		90							30		31					1.00		3.00																						1.00		3.00																		1.00					1.00							
S5768	018	0		29	10	S5768_018_0	2	2	Preferred Brand	1	2	000001		1	110100000010101000000001	30		90							2	30		90							30				31	14					43.35	25		25																					25		25																	25							25			
S5768	018	0		29	10	S5768_018_0	2	3	Non-Preferred Brand	1	2	100100		1	110100000010101000000101	30		90							2	30		90							30		31		31	14					66.76	45		45																					45		45																	45				45			45			
S5768	021	0		29	10	S5768_021_0	2	3	Non-Preferred Brand	1	2	100100		1	110100000010101000000101	30		90							2	30		90							30		31		31	14					63.35	47		47																					47		47																	47				47			47			
S5768	021	0		29	10	S5768_021_0	2	2	Preferred Brand	1	2	000001		1	110100000010101000000001	30		90							2	30		90							30				31	14					41.24	25		25																					25		25																	25							25			
S5768	021	0		29	10	S5768_021_0	2	1	Preferred Generic	1	2	001000		2	010100000010101000000100	30		90							2	30		90							30		31					1.00		3.00																						1.00		3.00																		1.00					1.00							
S5768	031	0		29	10	S5768_031_0	2	3	Non-Preferred Brand	1	2	100100		1	110100000010101000000101	30		90							2	30		90							30		31		31	14					67.78	45		45																					45		45																	45				45			45			
S5768	031	0		29	10	S5768_031_0	2	2	Preferred Brand	1	2	000001		1	110100000010101000000001	30		90							2	30		90							30				31	14					44.28	25		25																					25		25																	25							25			
S5768	031	0		29	10	S5768_031_0	2	1	Preferred Generic	1	2	001000		2	010100000010101000000100	30		90							2	30		90							30		31					1.00		3.00																						1.00		3.00																		1.00					1.00							
S5768	038	0		29	10	S5768_038_0	2	3	Non-Preferred Brand	1	2	100100		1	110100000010101000000101	30		90							2	30		90							30		31		31	14					68.36	42		42																					42		42																	42				42			42			
S5768	038	0		29	10	S5768_038_0	2	2	Preferred Brand	1	2	000001		1	110100000010101000000001	30		90							2	30		90							30				31	14					43.09	25		25																					25		25																	25							25			
S5768	038	0		29	10	S5768_038_0	2	1	Preferred Generic	1	2	001000		2	010100000010101000000100	30		90							2	30		90							30		31					1.00		3.00																						1.00		3.00																		1.00					1.00							
S5768	039	0		29	10	S5768_039_0	2	1	Preferred Generic	1	2	001000		2	010100000010101000000100	30		90							2	30		90							30		31					1.00		3.00																						1.00		3.00																		1.00					1.00							
S5768	039	0		29	10	S5768_039_0	2	2	Preferred Brand	1	2	000001		1	110100000010101000000001	30		90							2	30		90							30				31	14					43.41	25		25																					25		25																	25							25			
S5768	039	0		29	10	S5768_039_0	2	3	Non-Preferred Brand	1	2	100100		1	110100000010101000000101	30		90							2	30		90							30		31		31	14					61.96	48		48																					48		48																	48				48			48			
S5768	040	0		29	10	S5768_040_0	2	3	Non-Preferred Brand	1	2	100100		1	110100000010101000000101	30		90							2	30		90							30		31		31	14					66.48	46		46																					46		46																	46				46			46			
S5768	040	0		29	10	S5768_040_0	2	2	Preferred Brand	1	2	000001		1	110100000010101000000001	30		90							2	30		90							30				31	14					44.77	25		25																					25		25																	25							25			
S5768	040	0		29	10	S5768_040_0	2	1	Preferred Generic	1	2	001000		2	010100000010101000000100	30		90							2	30		90							30		31					1.00		3.00																						1.00		3.00																		1.00					1.00							
S5768	041	0		29	10	S5768_041_0	2	3	Non-Preferred Brand	1	2	100100		1	110100000010101000000101	30		90							2	30		90							30		31		31	14					58.89	45		45																					45		45																	45				45			45			
S5768	041	0		29	10	S5768_041_0	2	2	Preferred Brand	1	2	000001		1	110100000010101000000001	30		90							2	30		90							30				31	14					41.08	25		25																					25		25																	25							25			
S5768	041	0		29	10	S5768_041_0	2	1	Preferred Generic	1	2	001000		2	010100000010101000000100	30		90							2	30		90							30		31					1.00		3.00																						1.00		3.00																		1.00					1.00							
S5768	042	0		29	10	S5768_042_0	4	2	Preferred Brand	1	2	000001		1	110100000010101000000001	30		90							2	30		90							30				31	14					43.26	25		25																					25		25																	25							25			
S5768	042	0		29	10	S5768_042_0	4	3	Non-Preferred Brand	1	2	100100		1	110100000010101000000101	30		90							2	30		90							30		31		31	14					67.22	50		50																					50		50																	50				50			50			
S5768	042	0		29	10	S5768_042_0	4	1	Preferred Generic	1	2	001000		2	010100000010101000000100	30		90							2	30		90							30		31					1.00		3.00																						1.00		3.00																		1.00					1.00							
S5768	043	0		29	10	S5768_043_0	2	3	Non-Preferred Brand	1	2	100100		1	110100000010101000000101	30		90							2	30		90							30		31		31	14					66.54	45		45																					45		45																	45				45			45			
S5768	043	0		29	10	S5768_043_0	2	2	Preferred Brand	1	2	000001		1	110100000010101000000001	30		90							2	30		90							30				31	14					43.43	25		25																					25		25																	25							25			
S5768	043	0		29	10	S5768_043_0	2	1	Preferred Generic	1	2	001000		2	010100000010101000000100	30		90							2	30		90							30		31					1.00		3.00																						1.00		3.00																		1.00					1.00							
S5768	045	0		29	10	S5768_045_0	2	3	Non-Preferred Brand	1	2	100100		1	110100000010101000000101	30		90							2	30		90							30		31		31	14					66.75	42		42																					42		42																	42				42			42			
S5768	045	0		29	10	S5768_045_0	2	2	Preferred Brand	1	2	000001		1	110100000010101000000001	30		90							2	30		90							30				31	14					44.05	25		25																					25		25																	25							25			
S5768	045	0		29	10	S5768_045_0	2	1	Preferred Generic	1	2	001000		2	010100000010101000000100	30		90							2	30		90							30		31					1.00		3.00																						1.00		3.00																		1.00					1.00							
S5768	048	0		29	10	S5768_048_0	2	2	Preferred Brand	1	2	000001		1	110100000010101000000001	30		90							2	30		90							30				31	14					35.49	25		25																					25		25																	25							25			
S5768	048	0		29	10	S5768_048_0	2	3	Non-Preferred Brand	1	2	100100		1	110100000010101000000101	30		90							2	30		90							30		31		31	14					53.68	42		42																					42		42																	42				42			42			
S5768	048	0		29	10	S5768_048_0	2	1	Preferred Generic	1	2	001000		2	010100000010101000000100	30		90							2	30		90							30		31					1.00		3.00																						1.00		3.00																		1.00					1.00							
S5768	082	0		29	10	S5768_082_0	2	2	Preferred Brand	1	2	000001		1	110100000010101000000001	30		90							2	30		90							30				31	14					43.02	25		25																					25		25																	25							25			
S5768	082	0		29	10	S5768_082_0	2	3	Non-Preferred Brand	1	2	100100		1	110100000010101000000101	30		90							2	30		90							30		31		31	14					65.38	43		43																					43		43																	43				43			43			
S5768	082	0		29	10	S5768_082_0	2	1	Preferred Generic	1	2	001000		2	010100000010101000000100	30		90							2	30		90							30		31					1.00		3.00																						1.00		3.00																		1.00					1.00							
S5768	083	0		29	10	S5768_083_0	2	1	Preferred Generic	1	2	001000		2	010100000010101000000100	30		90							2	30		90							30		31					1.00		3.00																						1.00		3.00																		1.00					1.00							
S5768	083	0		29	10	S5768_083_0	2	2	Preferred Brand	1	2	000001		1	110100000010101000000001	30		90							2	30		90							30				31	14					43.38	25		25																					25		25																	25							25			
S5768	083	0		29	10	S5768_083_0	2	3	Non-Preferred Brand	1	2	100100		1	110100000010101000000101	30		90							2	30		90							30		31		31	14					71.30	46		46																					46		46																	46				46			46			
S5768	117	0		29	10	S5768_117_0	2	2	Preferred Brand	1	2	000001		1	110100000010101000000001	30		90							2	30		90							30				31	14					40.09	25		25																					25		25																	25							25			
S5768	117	0		29	10	S5768_117_0	2	1	Preferred Generic	1	2	001000		2	010100000010101000000100	30		90							2	30		90							30		31					1.00		3.00																						1.00		3.00																		1.00					1.00							
S5768	117	0		29	10	S5768_117_0	2	3	Non-Preferred Brand	1	2	100100		1	110100000010101000000101	30		90							2	30		90							30		31		31	14					54.62	39		39																					39		39																	39				39			39			
S5768	118	0		29	10	S5768_118_0	2	2	Preferred Brand	1	2	000001		1	110100000010101000000001	30		90							2	30		90							30				31	14					42.37	25		25																					25		25																	25							25			
S5768	118	0		29	10	S5768_118_0	2	1	Preferred Generic	1	2	001000		2	010100000010101000000100	30		90							2	30		90							30		31					1.00		3.00																						1.00		3.00																		1.00					1.00							
S5768	118	0		29	10	S5768_118_0	2	3	Non-Preferred Brand	1	2	100100		1	110100000010101000000101	30		90							2	30		90							30		31		31	14					66.13	45		45																					45		45																	45				45			45			
S5768	119	0		29	10	S5768_119_0	2	2	Preferred Brand	1	2	000001		1	110100000010101000000001	30		90							2	30		90							30				31	14					44.02	25		25																					25		25																	25							25			
S5768	119	0		29	10	S5768_119_0	2	3	Non-Preferred Brand	1	2	100100		1	110100000010101000000101	30		90							2	30		90							30		31		31	14					64.30	44		44																					44		44																	44				44			44			
S5768	119	0		29	10	S5768_119_0	2	1	Preferred Generic	1	2	001000		2	010100000010101000000100	30		90							2	30		90							30		31					1.00		3.00																						1.00		3.00																		1.00					1.00							
S5768	122	0		29	10	S5768_122_0	2	3	Non-Preferred Brand	1	2	100100		1	110100000010101000000101	30		90							2	30		90							30		31		31	14					66.30	43		43																					43		43																	43				43			43			
S5768	122	0		29	10	S5768_122_0	2	1	Preferred Generic	1	2	001000		2	010100000010101000000100	30		90							2	30		90							30		31					1.00		3.00																						1.00		3.00																		1.00					1.00							
S5768	122	0		29	10	S5768_122_0	2	2	Preferred Brand	1	2	000001		1	110100000010101000000001	30		90							2	30		90							30				31	14					42.04	25		25																					25		25																	25							25			
S5768	123	0		29	10	S5768_123_0	2	2	Preferred Brand	1	2	000001		1	110100000010101000000001	30		90							2	30		90							30				31	14					41.26	25		25																					25		25																	25							25			
S5768	123	0		29	10	S5768_123_0	2	1	Preferred Generic	1	2	001000		2	010100000010101000000100	30		90							2	30		90							30		31					1.00		3.00																						1.00		3.00																		1.00					1.00							
S5768	123	0		29	10	S5768_123_0	2	3	Non-Preferred Brand	1	2	100100		1	110100000010101000000101	30		90							2	30		90							30		31		31	14					70.07	46		46																					46		46																	46				46			46			
S5768	125	0		29	10	S5768_125_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	2										30		31													0.00		0.00						7.00		21.00																										7.00					7.00							
S5768	125	0		29	10	S5768_125_0	2	2	Preferred Brand	1	4	000001	1	2	100010110110000000000001				30		90	30		90	2										30				31	14										35.00		105.00						45.00		135.00																										45.00								45.00				
S5768	125	0		29	10	S5768_125_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000000000101				30		90	30		90	2										30		31		31	14										70.00		210.00						95.00		285.00																										95.00					95.00			95.00				
S5768	125	0		29	10	S5768_125_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													485.13	33							485.13	33																										33				33			33			
S5768	126	0		29	10	S5768_126_0	2	2	Preferred Brand	1	4	000001	1	2	100010110110000000000001				30		90	30		90	2										30				31	14										35.00		105.00						45.00		135.00																										45.00								45.00				
S5768	126	0		29	10	S5768_126_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000000000101				30		90	30		90	2										30		31		31	14										70.00		210.00						95.00		285.00																										95.00					95.00			95.00				
S5768	126	0		29	10	S5768_126_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													523.08	33							523.08	33																										33				33			33			
S5768	126	0		29	10	S5768_126_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	2										30		31													0.00		0.00						7.00		21.00																										7.00					7.00							
S5768	127	0		29	10	S5768_127_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000000000101				30		90	30		90	2										30		31		31	14										70.00		210.00						95.00		285.00																										95.00					95.00			95.00				
S5768	127	0		29	10	S5768_127_0	2	2	Preferred Brand	1	4	000001	1	2	100010110110000000000001				30		90	30		90	2										30				31	14										35.00		105.00						45.00		135.00																										45.00								45.00				
S5768	127	0		29	10	S5768_127_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	2										30		31													0.00		0.00						7.00		21.00																										7.00					7.00							
S5768	127	0		29	10	S5768_127_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													525.03	33							525.03	33																										33				33			33			
S5768	128	0		29	10	S5768_128_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	2										30		31													0.00		0.00						7.00		21.00																										7.00					7.00							
S5768	128	0		29	10	S5768_128_0	2	2	Preferred Brand	1	4	000001	1	2	100010110110000000000001				30		90	30		90	2										30				31	14										35.00		105.00						45.00		135.00																										45.00								45.00				
S5768	128	0		29	10	S5768_128_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000000000101				30		90	30		90	2										30		31		31	14										70.00		210.00						95.00		285.00																										95.00					95.00			95.00				
S5768	128	0		29	10	S5768_128_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													476.32	33							476.32	33																										33				33			33			
S5768	129	0		29	10	S5768_129_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	2										30		31													0.00		0.00						7.00		21.00																										7.00					7.00							
S5768	129	0		29	10	S5768_129_0	2	2	Preferred Brand	1	4	000001	1	2	100010110110000000000001				30		90	30		90	2										30				31	14										35.00		105.00						45.00		135.00																										45.00								45.00				
S5768	129	0		29	10	S5768_129_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													456.01	33							456.01	33																										33				33			33			
S5768	129	0		29	10	S5768_129_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000000000101				30		90	30		90	2										30		31		31	14										70.00		210.00						95.00		285.00																										95.00					95.00			95.00				
S5768	130	0		29	10	S5768_130_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	2										30		31													0.00		0.00						7.00		21.00																										7.00					7.00							
S5768	130	0		29	10	S5768_130_0	2	2	Preferred Brand	1	4	000001	1	2	100010110110000000000001				30		90	30		90	2										30				31	14										35.00		105.00						45.00		135.00																										45.00								45.00				
S5768	130	0		29	10	S5768_130_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000000000101				30		90	30		90	2										30		31		31	14										70.00		210.00						95.00		285.00																										95.00					95.00			95.00				
S5768	130	0		29	10	S5768_130_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													436.78	33							436.78	33																										33				33			33			
S5768	131	0		29	10	S5768_131_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	2										30		31													0.00		0.00						7.00		21.00																										7.00					7.00							
S5768	131	0		29	10	S5768_131_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000000000101				30		90	30		90	2										30		31		31	14										70.00		210.00						95.00		285.00																										95.00					95.00			95.00				
S5768	131	0		29	10	S5768_131_0	2	2	Preferred Brand	1	4	000001	1	2	100010110110000000000001				30		90	30		90	2										30				31	14										35.00		105.00						45.00		135.00																										45.00								45.00				
S5768	131	0		29	10	S5768_131_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													478.69	33							478.69	33																										33				33			33			
S5768	132	0		29	10	S5768_132_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000000000101				30		90	30		90	2										30		31		31	14										70.00		210.00						95.00		285.00																										95.00					95.00			95.00				
S5768	132	0		29	10	S5768_132_0	2	2	Preferred Brand	1	4	000001	1	2	100010110110000000000001				30		90	30		90	2										30				31	14										35.00		105.00						45.00		135.00																										45.00								45.00				
S5768	132	0		29	10	S5768_132_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	2										30		31													0.00		0.00						7.00		21.00																										7.00					7.00							
S5768	132	0		29	10	S5768_132_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													525.26	33							525.26	33																										33				33			33			
S5768	133	0		29	10	S5768_133_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000000000101				30		90	30		90	2										30		31		31	14										70.00		210.00						95.00		285.00																										95.00					95.00			95.00				
S5768	133	0		29	10	S5768_133_0	2	2	Preferred Brand	1	4	000001	1	2	100010110110000000000001				30		90	30		90	2										30				31	14										35.00		105.00						45.00		135.00																										45.00								45.00				
S5768	133	0		29	10	S5768_133_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	2										30		31													0.00		0.00						7.00		21.00																										7.00					7.00							
S5768	133	0		29	10	S5768_133_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													467.89	33							467.89	33																										33				33			33			
S5768	134	0		29	10	S5768_134_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	2										30		31													0.00		0.00						7.00		21.00																										7.00					7.00							
S5768	134	0		29	10	S5768_134_0	2	2	Preferred Brand	1	4	000001	1	2	100010110110000000000001				30		90	30		90	2										30				31	14										35.00		105.00						45.00		135.00																										45.00								45.00				
S5768	134	0		29	10	S5768_134_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000000000101				30		90	30		90	2										30		31		31	14										70.00		210.00						95.00		285.00																										95.00					95.00			95.00				
S5768	134	0		29	10	S5768_134_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													583.79	33							583.79	33																										33				33			33			
S5768	135	0		29	10	S5768_135_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000000000101				30		90	30		90	2										30		31		31	14										70.00		210.00						95.00		285.00																										95.00					95.00			95.00				
S5768	135	0		29	10	S5768_135_0	2	2	Preferred Brand	1	4	000001	1	2	100010110110000000000001				30		90	30		90	2										30				31	14										35.00		105.00						45.00		135.00																										45.00								45.00				
S5768	135	0		29	10	S5768_135_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	2										30		31													0.00		0.00						7.00		21.00																										7.00					7.00							
S5768	135	0		29	10	S5768_135_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													461.18	33							461.18	33																										33				33			33			
S5768	136	0		29	10	S5768_136_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	2										30		31													0.00		0.00						7.00		21.00																										7.00					7.00							
S5768	136	0		29	10	S5768_136_0	2	2	Preferred Brand	1	4	000001	1	2	100010110110000000000001				30		90	30		90	2										30				31	14										35.00		105.00						45.00		135.00																										45.00								45.00				
S5768	136	0		29	10	S5768_136_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000000000101				30		90	30		90	2										30		31		31	14										70.00		210.00						95.00		285.00																										95.00					95.00			95.00				
S5768	136	0		29	10	S5768_136_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													496.52	33							496.52	33																										33				33			33			
S5768	137	0		29	10	S5768_137_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	2										30		31													0.00		0.00						7.00		21.00																										7.00					7.00							
S5768	137	0		29	10	S5768_137_0	2	2	Preferred Brand	1	4	000001	1	2	100010110110000000000001				30		90	30		90	2										30				31	14										35.00		105.00						45.00		135.00																										45.00								45.00				
S5768	137	0		29	10	S5768_137_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													466.44	33							466.44	33																										33				33			33			
S5768	137	0		29	10	S5768_137_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000000000101				30		90	30		90	2										30		31		31	14										70.00		210.00						95.00		285.00																										95.00					95.00			95.00				
S5768	138	0		29	10	S5768_138_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	2										30		31													0.00		0.00						7.00		21.00																										7.00					7.00							
S5768	138	0		29	10	S5768_138_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000000000101				30		90	30		90	2										30		31		31	14										70.00		210.00						95.00		285.00																										95.00					95.00			95.00				
S5768	138	0		29	10	S5768_138_0	2	2	Preferred Brand	1	4	000001	1	2	100010110110000000000001				30		90	30		90	2										30				31	14										35.00		105.00						45.00		135.00																										45.00								45.00				
S5768	138	0		29	10	S5768_138_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													478.82	33							478.82	33																										33				33			33			
S5768	139	0		29	10	S5768_139_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	2										30		31													0.00		0.00						7.00		21.00																										7.00					7.00							
S5768	139	0		29	10	S5768_139_0	2	2	Preferred Brand	1	4	000001	1	2	100010110110000000000001				30		90	30		90	2										30				31	14										35.00		105.00						45.00		135.00																										45.00								45.00				
S5768	139	0		29	10	S5768_139_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000000000101				30		90	30		90	2										30		31		31	14										70.00		210.00						95.00		285.00																										95.00					95.00			95.00				
S5768	139	0		29	10	S5768_139_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													463.87	33							463.87	33																										33				33			33			
S5768	140	0		29	10	S5768_140_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	2										30		31													0.00		0.00						7.00		21.00																										7.00					7.00							
S5768	140	0		29	10	S5768_140_0	2	2	Preferred Brand	1	4	000001	1	2	100010110110000000000001				30		90	30		90	2										30				31	14										35.00		105.00						45.00		135.00																										45.00								45.00				
S5768	140	0		29	10	S5768_140_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000000000101				30		90	30		90	2										30		31		31	14										70.00		210.00						95.00		285.00																										95.00					95.00			95.00				
S5768	140	0		29	10	S5768_140_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													489.21	33							489.21	33																										33				33			33			
S5768	141	0		29	10	S5768_141_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	2										30		31													0.00		0.00						7.00		21.00																										7.00					7.00							
S5768	141	0		29	10	S5768_141_0	2	2	Preferred Brand	1	4	000001	1	2	100010110110000000000001				30		90	30		90	2										30				31	14										35.00		105.00						45.00		135.00																										45.00								45.00				
S5768	141	0		29	10	S5768_141_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000000000101				30		90	30		90	2										30		31		31	14										70.00		210.00						95.00		285.00																										95.00					95.00			95.00				
S5768	141	0		29	10	S5768_141_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													459.83	33							459.83	33																										33				33			33			
S5768	142	0		29	10	S5768_142_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000000000101				30		90	30		90	2										30		31		31	14										70.00		210.00						95.00		285.00																										95.00					95.00			95.00				
S5768	142	0		29	10	S5768_142_0	2	2	Preferred Brand	1	4	000001	1	2	100010110110000000000001				30		90	30		90	2										30				31	14										35.00		105.00						45.00		135.00																										45.00								45.00				
S5768	142	0		29	10	S5768_142_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	2										30		31													0.00		0.00						7.00		21.00																										7.00					7.00							
S5768	142	0		29	10	S5768_142_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													438.30	33							438.30	33																										33				33			33			
S5768	143	0		29	10	S5768_143_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													438.08	33							438.08	33																										33				33			33			
S5768	143	0		29	10	S5768_143_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	2										30		31													0.00		0.00						7.00		21.00																										7.00					7.00							
S5768	143	0		29	10	S5768_143_0	2	2	Preferred Brand	1	4	000001	1	2	100010110110000000000001				30		90	30		90	2										30				31	14										35.00		105.00						45.00		135.00																										45.00								45.00				
S5768	143	0		29	10	S5768_143_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000000000101				30		90	30		90	2										30		31		31	14										70.00		210.00						95.00		285.00																										95.00					95.00			95.00				
S5768	144	0		29	10	S5768_144_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													466.44	33							466.44	33																										33				33			33			
S5768	144	0		29	10	S5768_144_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000000000101				30		90	30		90	2										30		31		31	14										70.00		210.00						95.00		285.00																										95.00					95.00			95.00				
S5768	144	0		29	10	S5768_144_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	2										30		31													0.00		0.00						7.00		21.00																										7.00					7.00							
S5768	144	0		29	10	S5768_144_0	2	2	Preferred Brand	1	4	000001	1	2	100010110110000000000001				30		90	30		90	2										30				31	14										35.00		105.00						45.00		135.00																										45.00								45.00				
S5768	145	0		29	10	S5768_145_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	2										30		31													0.00		0.00						7.00		21.00																										7.00					7.00							
S5768	145	0		29	10	S5768_145_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													499.98	33							499.98	33																										33				33			33			
S5768	145	0		29	10	S5768_145_0	2	2	Preferred Brand	1	4	000001	1	2	100010110110000000000001				30		90	30		90	2										30				31	14										35.00		105.00						45.00		135.00																										45.00								45.00				
S5768	145	0		29	10	S5768_145_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000000000101				30		90	30		90	2										30		31		31	14										70.00		210.00						95.00		285.00																										95.00					95.00			95.00				
S5768	146	0		29	10	S5768_146_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													507.16	33							507.16	33																										33				33			33			
S5768	146	0		29	10	S5768_146_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000000000101				30		90	30		90	2										30		31		31	14										70.00		210.00						95.00		285.00																										95.00					95.00			95.00				
S5768	146	0		29	10	S5768_146_0	2	2	Preferred Brand	1	4	000001	1	2	100010110110000000000001				30		90	30		90	2										30				31	14										35.00		105.00						45.00		135.00																										45.00								45.00				
S5768	146	0		29	10	S5768_146_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	2										30		31													0.00		0.00						7.00		21.00																										7.00					7.00							
S5768	147	0		29	10	S5768_147_0	2	2	Preferred Brand	1	4	000001	1	2	100010110110000000000001				30		90	30		90	2										30				31	14										35.00		105.00						45.00		135.00																										45.00								45.00				
S5768	147	0		29	10	S5768_147_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000000000101				30		90	30		90	2										30		31		31	14										70.00		210.00						95.00		285.00																										95.00					95.00			95.00				
S5768	147	0		29	10	S5768_147_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													413.33	33							413.33	33																										33				33			33			
S5768	147	0		29	10	S5768_147_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	2										30		31													0.00		0.00						7.00		21.00																										7.00					7.00							
S5768	148	0		29	10	S5768_148_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000000000101				30		90	30		90	2										30		31		31	14										70.00		210.00						95.00		285.00																										95.00					95.00			95.00				
S5768	148	0		29	10	S5768_148_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	2										30		31													0.00		0.00						7.00		21.00																										7.00					7.00							
S5768	148	0		29	10	S5768_148_0	2	2	Preferred Brand	1	4	000001	1	2	100010110110000000000001				30		90	30		90	2										30				31	14										35.00		105.00						45.00		135.00																										45.00								45.00				
S5768	148	0		29	10	S5768_148_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													424.34	33							424.34	33																										33				33			33			
S5768	149	0		29	10	S5768_149_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													444.52	33							444.52	33																										33				33			33			
S5768	149	0		29	10	S5768_149_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000000000101				30		90	30		90	2										30		31		31	14										70.00		210.00						95.00		285.00																										95.00					95.00			95.00				
S5768	149	0		29	10	S5768_149_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	2										30		31													0.00		0.00						7.00		21.00																										7.00					7.00							
S5768	149	0		29	10	S5768_149_0	2	2	Preferred Brand	1	4	000001	1	2	100010110110000000000001				30		90	30		90	2										30				31	14										35.00		105.00						45.00		135.00																										45.00								45.00				
S5768	150	0		29	10	S5768_150_0	2	2	Preferred Brand	1	4	000001	1	2	100010110110000000000001				30		90	30		90	2										30				31	14										35.00		105.00						45.00		135.00																										45.00								45.00				
S5768	150	0		29	10	S5768_150_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000000000101				30		90	30		90	2										30		31		31	14										70.00		210.00						95.00		285.00																										95.00					95.00			95.00				
S5768	150	0		29	10	S5768_150_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													491.72	33							491.72	33																										33				33			33			
S5768	150	0		29	10	S5768_150_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	2										30		31													0.00		0.00						7.00		21.00																										7.00					7.00							
S5768	151	0		29	10	S5768_151_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	2										30		31													0.00		0.00						7.00		21.00																										7.00					7.00							
S5768	151	0		29	10	S5768_151_0	2	2	Preferred Brand	1	4	000001	1	2	100010110110000000000001				30		90	30		90	2										30				31	14										35.00		105.00						45.00		135.00																										45.00								45.00				
S5768	151	0		29	10	S5768_151_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000000000101				30		90	30		90	2										30		31		31	14										70.00		210.00						95.00		285.00																										95.00					95.00			95.00				
S5768	151	0		29	10	S5768_151_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													469.38	33							469.38	33																										33				33			33			
S5768	152	0		29	10	S5768_152_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	2										30		31													0.00		0.00						7.00		21.00																										7.00					7.00							
S5768	152	0		29	10	S5768_152_0	2	2	Preferred Brand	1	4	000001	1	2	100010110110000000000001				30		90	30		90	2										30				31	14										35.00		105.00						45.00		135.00																										45.00								45.00				
S5768	152	0		29	10	S5768_152_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000000000101				30		90	30		90	2										30		31		31	14										70.00		210.00						95.00		285.00																										95.00					95.00			95.00				
S5768	152	0		29	10	S5768_152_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													529.97	33							529.97	33																										33				33			33			
S5768	153	0		29	10	S5768_153_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	2										30		31													0.00		0.00						7.00		21.00																										7.00					7.00							
S5768	153	0		29	10	S5768_153_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													447.05	33							447.05	33																										33				33			33			
S5768	153	0		29	10	S5768_153_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000000000101				30		90	30		90	2										30		31		31	14										70.00		210.00						95.00		285.00																										95.00					95.00			95.00				
S5768	153	0		29	10	S5768_153_0	2	2	Preferred Brand	1	4	000001	1	2	100010110110000000000001				30		90	30		90	2										30				31	14										35.00		105.00						45.00		135.00																										45.00								45.00				
S5768	154	0		29	10	S5768_154_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	2										30		31													0.00		0.00						7.00		21.00																										7.00					7.00							
S5768	154	0		29	10	S5768_154_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													441.25	33							441.25	33																										33				33			33			
S5768	154	0		29	10	S5768_154_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000000000101				30		90	30		90	2										30		31		31	14										70.00		210.00						95.00		285.00																										95.00					95.00			95.00				
S5768	154	0		29	10	S5768_154_0	2	2	Preferred Brand	1	4	000001	1	2	100010110110000000000001				30		90	30		90	2										30				31	14										35.00		105.00						45.00		135.00																										45.00								45.00				
S5768	155	0		29	10	S5768_155_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000000000101				30			30													30		31		31	14													433.17	33							433.17	33																										33				33			33			
S5768	155	0		29	10	S5768_155_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000000000101				30		90	30		90	2										30		31		31	14										70.00		210.00						95.00		285.00																										95.00					95.00			95.00				
S5768	155	0		29	10	S5768_155_0	2	1	Preferred Generic	1	4	001000	1	2	000010110110000000000100				30		90	30		90	2										30		31													0.00		0.00						7.00		21.00																										7.00					7.00							
S5768	155	0		29	10	S5768_155_0	2	2	Preferred Brand	1	4	000001	1	2	100010110110000000000001				30		90	30		90	2										30				31	14										35.00		105.00						45.00		135.00																										45.00								45.00				
S5768	158	0		29	10	S5768_158_0	3	3	Non-Preferred Brand	1	2	100100		1	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14													44.44	30		30					59.25	40		40					30		30																	40				40			40			
S5768	158	0		29	10	S5768_158_0	3	2	Preferred Brand	1	2	000001		1	100010110110101000000001				30		90	30		90	2	30		90							30				31	14													27.92	20		20					34.90	25		25					20		20																	25							25			
S5768	158	0		29	10	S5768_158_0	3	1	Preferred Generic	1	2	001000		2	000010110110101000000100				30		90	30		90	2	30		90							30		31													1.15		3.45						3.00		9.00						1.15		3.45																		3.00					3.00							
S5768	159	0		29	10	S5768_159_0	3	3	Non-Preferred Brand	1	2	100100		1	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14													45.26	29		29					60.87	39		39					29		29																	39				39			39			
S5768	159	0		29	10	S5768_159_0	3	1	Preferred Generic	1	2	001000		2	000010110110101000000100				30		90	30		90	2	30		90							30		31													1.15		3.45						3.00		9.00						1.15		3.45																		3.00					3.00							
S5768	159	0		29	10	S5768_159_0	3	2	Preferred Brand	1	2	000001		1	100010110110101000000001				30		90	30		90	2	30		90							30				31	14													27.13	20		20					33.91	25		25					20		20																	25							25			
S5768	160	0		29	10	S5768_160_0	3	1	Preferred Generic	1	2	001000		2	000010110110101000000100				30		90	30		90	2	30		90							30		31													1.15		3.45						3.00		9.00						1.15		3.45																		3.00					3.00							
S5768	160	0		29	10	S5768_160_0	3	2	Preferred Brand	1	2	000001		1	100010110110101000000001				30		90	30		90	2	30		90							30				31	14													27.62	20		20					34.52	25		25					20		20																	25							25			
S5768	160	0		29	10	S5768_160_0	3	3	Non-Preferred Brand	1	2	100100		1	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14													47.29	30		30					63.05	40		40					30		30																	40				40			40			
S5768	161	0		29	10	S5768_161_0	3	1	Preferred Generic	1	2	001000		2	000010110110101000000100				30		90	30		90	2	30		90							30		31													1.15		3.45						3.00		9.00						1.15		3.45																		3.00					3.00							
S5768	161	0		29	10	S5768_161_0	3	2	Preferred Brand	1	2	000001		1	100010110110101000000001				30		90	30		90	2	30		90							30				31	14													26.46	20		20					33.08	25		25					20		20																	25							25			
S5768	161	0		29	10	S5768_161_0	3	3	Non-Preferred Brand	1	2	100100		1	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14													47.62	28		28					64.62	38		38					28		28																	38				38			38			
S5768	162	0		29	10	S5768_162_0	3	3	Non-Preferred Brand	1	2	100100		1	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14													45.78	30		30					61.04	40		40					30		30																	40				40			40			
S5768	162	0		29	10	S5768_162_0	3	2	Preferred Brand	1	2	000001		1	100010110110101000000001				30		90	30		90	2	30		90							30				31	14													27.14	20		20					33.93	25		25					20		20																	25							25			
S5768	162	0		29	10	S5768_162_0	3	1	Preferred Generic	1	2	001000		2	000010110110101000000100				30		90	30		90	2	30		90							30		31													1.15		3.45						3.00		9.00						1.15		3.45																		3.00					3.00							
S5768	163	0		29	10	S5768_163_0	3	2	Preferred Brand	1	2	000001		1	100010110110101000000001				30		90	30		90	2	30		90							30				31	14													28.81	20		20					36.01	25		25					20		20																	25							25			
S5768	163	0		29	10	S5768_163_0	3	3	Non-Preferred Brand	1	2	100100		1	100010110110101000000101				30		90	30		90	2	30		90							30		31		31	14													49.29	29		29					66.29	39		39					29		29																	39				39			39			
S5768	163	0		29	10	S5768_163_0	3	1	Preferred Generic	1	2	001000		2	000010110110101000000100				30		90	30		90	2	30		90							30		31													1.15		3.45						3.00		9.00						1.15		3.45																		3.00					3.00							
S5775	001	0		29	10	S5775_001_0	4	3	Non-Preferred Brand	1	4	100000	3	2	100010110110101000000001				30		90	30		90	1	30		90							30				31	14										58.00		174.00						73.00		219.00						58.00		174.00																		73.00								58.00				
S5775	001	0		29	10	S5775_001_0	4	2	Preferred Brand	1	4	000001	1	2	100010110110101000000001				30		90	30		90	1	30		90							30				31	14										25.00		75.00						40.00		120.00						25.00		75.00																		40.00								25.00				
S5775	001	0		29	10	S5775_001_0	4	1	Generic	1	4	010000	1	2	000010110110101000000100				30		90	30		90	1	30		90							30		31													3.00		9.00						8.75		26.25						3.00		9.00																		8.75					3.00							
S5775	001	0		29	10	S5775_001_0	4	4	Specialty Tier	1	4	110000	1	1	100010110110101000000101				30		90	30		90	1	30		90							30		31		31	14													500.00	33		33					500.00	33		33					33		33																	33				33			33			
S5775	002	0		29	10	S5775_002_0	4	3	Non-Preferred Brand	1	3	100000		2	100010110110101000000001				30		90	30		90	1	30		90							30				31	14										60.00		180.00						75.00		225.00						60.00		180.00																		75.00								60.00				
S5775	002	0		29	10	S5775_002_0	4	2	Preferred Brand	1	3	000001		2	100010110110101000000001				30		90	30		90	1	30		90							30				31	14										30.00		90.00						45.00		135.00						30.00		90.00																		45.00								30.00				
S5775	002	0		29	10	S5775_002_0	4	1	Generic	1	3	010000		2	000010110110101000000100				30		90	30		90	1	30		90							30		31													6.00		18.00						9.50		28.50						6.00		18.00																		9.50					6.00							
S5775	002	0		29	10	S5775_002_0	4	4	Specialty Tier	1	3	110000		1	100010110110101000000101				30		90	30		90	1	30		90							30		31		31	14													500.00	25		25					500.00	25		25					25		25																	25				25			25			
S5795	002	0		29	10	S5795_002_0	2	1	Generic	1	4	010000	1	2	010100000010101000000100	34		90							1	34		90							34		34					6.00		15.00																						6.00		15.00																		6.00					6.00							
S5795	002	0		29	10	S5795_002_0	2	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	34		90							1	34		90							34				34	14		45.00		112.50																						45.00		112.50																		45.00								45.00				
S5795	002	0		29	10	S5795_002_0	2	3	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	34		90							1	34		90							34				34	14		84.00		210.00																						84.00		210.00																		84.00								84.00				
S5795	002	0		29	10	S5795_002_0	2	4	Specialty Tier	1	4	010010	1	1	110100000010101000000101	34		90							1	34		90							34		34		34	14					354.35	25		25																					25		25																	25				25			25			
S5795	002	0		29	10	S5795_002_0	2	1	Generic	3	4	010000	1	2	010100000010101000000100	34		90							1	34		90							34		34					6.00		15.00																						6.00		15.00																		6.00					6.00					1		
S5795	003	0		29	10	S5795_003_0	3	1	Preferred Generic	1	3	001000		2	010100000010101000000100	34		90							1	34		90							34		34					4.00		8.00																						4.00		8.00																		4.00					4.00							
S5795	003	0		29	10	S5795_003_0	3	2	Non-Preferred Generic	1	3	000100		2	010100000010101000000100	34		90							1	34		90							34		34					11.00		27.50																						11.00		27.50																		11.00					11.00							
S5795	003	0		29	10	S5795_003_0	3	3	Preferred Brand	1	3	000001		1	110100000010101000000001	34		90							1	34		90							34				34	14					31.53	20		20																					20		20																	20							20			
S5795	003	0		29	10	S5795_003_0	3	4	Non-Preferred Brand	1	3	100000		1	110100000010101000000001	34		90							1	34		90							34				34	14					69.70	31		31																					31		31																	31							31			
S5795	003	0		29	10	S5795_003_0	3	5	Specialty Tier	1	3	010010		1	110100000010101000000101	34		90							1	34		90							34		34		34	14					354.35	25		25																					25		25																	25				25			25			
S5805	001	0		29	10	S5805_001_0	6	1	Preferred Generic	1	3	001000		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													3.00		9.00						7.00		21.00															9.00							21.00				7.00					7.00							
S5805	001	0		29	10	S5805_001_0	6	2	Non-Preferred Generic	1	3	000100		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						10.00		30.00															15.00							30.00				10.00					10.00							
S5805	001	0		29	10	S5805_001_0	6	5	Specialty Tier	1	3	010010		1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													534.00	33		33					534.00	33		33														33							33			33				33			33			
S5805	001	0		29	10	S5805_001_0	6	4	Non-Preferred Brand	1	3	100100		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										90.00		270.00						95.00		285.00															270.00							285.00				95.00					95.00			95.00				
S5805	001	0		29	10	S5805_001_0	6	3	Preferred Brand	1	3	010001		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															120.00							135.00				45.00					45.00			45.00				
S5810	035	0		29	10	S5810_035_0	2	3	Preferred Brand	1	2	000001		2	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14										40.00	80.00	120.00						40.00	80.00	120.00						40.00	80.00	120.00																			40.00							40.00				
S5810	035	0		29	10	S5810_035_0	2	2	Non-Preferred Generic	1	2	000100		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													5.00	10.00	15.00						10.00	20.00	30.00						5.00	10.00	15.00																			10.00				10.00							
S5810	035	0		29	10	S5810_035_0	2	1	Preferred Generic	1	2	001000		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													2.00	4.00	6.00						7.00	14.00	21.00						2.00	4.00	5.00																			7.00				7.00							
S5810	035	0		29	10	S5810_035_0	2	4	Non-Preferred Brand	1	2	100000		1	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14													88.19	48	48	48					88.19	48	48	48					48	48	48																		48						48			
S5810	035	0		29	10	S5810_035_0	2	5	Specialty Tier	1	2	010010		1	100011111101111000000101				31	60	90	31	60	90	1	31	60	90								10	31		31	14													294.27	25	25	25					294.27	25	25	25					25	25	25																		25			25			25			
S5810	036	0		29	10	S5810_036_0	2	5	Specialty Tier	1	2	010010		1	100011111101111000000101				31	60	90	31	60	90	1	31	60	90								10	31		31	14													268.45	25	25	25					268.45	25	25	25					25	25	25																		25			25			25			
S5810	036	0		29	10	S5810_036_0	2	1	Preferred Generic	1	2	001000		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													2.00	4.00	6.00						7.00	14.00	21.00						2.00	4.00	5.00																			7.00				7.00							
S5810	036	0		29	10	S5810_036_0	2	2	Non-Preferred Generic	1	2	000100		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													5.00	10.00	15.00						28.00	56.00	84.00						5.00	10.00	15.00																			28.00				28.00							
S5810	036	0		29	10	S5810_036_0	2	4	Non-Preferred Brand	1	2	100000		1	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14													94.52	38	38	38					94.52	38	38	38					38	38	38																		38						38			
S5810	036	0		29	10	S5810_036_0	2	3	Preferred Brand	1	2	000001		2	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14										45.00	90.00	135.00						45.00	90.00	135.00						45.00	90.00	135.00																			45.00							45.00				
S5810	037	0		29	10	S5810_037_0	2	2	Non-Preferred Generic	1	2	000100		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													5.00	10.00	15.00						33.00	66.00	99.00						5.00	10.00	15.00																			33.00				33.00							
S5810	037	0		29	10	S5810_037_0	2	3	Preferred Brand	1	2	000001		2	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14										45.00	90.00	135.00						45.00	90.00	135.00						45.00	90.00	135.00																			45.00							45.00				
S5810	037	0		29	10	S5810_037_0	2	5	Specialty Tier	1	2	010010		1	100011111101111000000101				31	60	90	31	60	90	1	31	60	90								10	31		31	14													315.53	25	25	25					315.53	25	25	25					25	25	25																		25			25			25			
S5810	037	0		29	10	S5810_037_0	2	4	Non-Preferred Brand	1	2	100000		1	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14													93.90	44	44	44					93.90	44	44	44					44	44	44																		44						44			
S5810	037	0		29	10	S5810_037_0	2	1	Preferred Generic	1	2	001000		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													2.00	4.00	6.00						7.00	14.00	21.00						2.00	4.00	5.00																			7.00				7.00							
S5810	038	0		29	10	S5810_038_0	2	3	Preferred Brand	1	2	000001		2	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14										45.00	90.00	135.00						45.00	90.00	135.00						45.00	90.00	135.00																			45.00							45.00				
S5810	038	0		29	10	S5810_038_0	2	2	Non-Preferred Generic	1	2	000100		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													5.00	10.00	15.00						33.00	66.00	99.00						5.00	10.00	15.00																			33.00				33.00							
S5810	038	0		29	10	S5810_038_0	2	1	Preferred Generic	1	2	001000		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													2.00	4.00	6.00						7.00	14.00	21.00						2.00	4.00	5.00																			7.00				7.00							
S5810	038	0		29	10	S5810_038_0	2	4	Non-Preferred Brand	1	2	100000		1	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14													93.76	44	44	44					93.76	44	44	44					44	44	44																		44						44			
S5810	038	0		29	10	S5810_038_0	2	5	Specialty Tier	1	2	010010		1	100011111101111000000101				31	60	90	31	60	90	1	31	60	90								10	31		31	14													334.79	25	25	25					334.79	25	25	25					25	25	25																		25			25			25			
S5810	039	0		29	10	S5810_039_0	2	4	Non-Preferred Brand	1	2	100000		1	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14													94.10	39	39	39					94.10	39	39	39					39	39	39																		39						39			
S5810	039	0		29	10	S5810_039_0	2	3	Preferred Brand	1	2	000001		2	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14										45.00	90.00	135.00						45.00	90.00	135.00						45.00	90.00	135.00																			45.00							45.00				
S5810	039	0		29	10	S5810_039_0	2	2	Non-Preferred Generic	1	2	000100		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													5.00	10.00	15.00						33.00	66.00	99.00						5.00	10.00	15.00																			33.00				33.00							
S5810	039	0		29	10	S5810_039_0	2	1	Preferred Generic	1	2	001000		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													2.00	4.00	6.00						7.00	14.00	21.00						2.00	4.00	5.00																			7.00				7.00							
S5810	039	0		29	10	S5810_039_0	2	5	Specialty Tier	1	2	010010		1	100011111101111000000101				31	60	90	31	60	90	1	31	60	90								10	31		31	14													360.16	25	25	25					360.16	25	25	25					25	25	25																		25			25			25			
S5810	040	0		29	10	S5810_040_0	2	3	Preferred Brand	1	2	000001		2	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14										45.00	90.00	135.00						45.00	90.00	135.00						45.00	90.00	135.00																			45.00							45.00				
S5810	040	0		29	10	S5810_040_0	2	2	Non-Preferred Generic	1	2	000100		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													5.00	10.00	15.00						30.00	60.00	90.00						5.00	10.00	15.00																			30.00				30.00							
S5810	040	0		29	10	S5810_040_0	2	4	Non-Preferred Brand	1	2	100000		1	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14													93.63	46	46	46					93.63	46	46	46					46	46	46																		46						46			
S5810	040	0		29	10	S5810_040_0	2	1	Preferred Generic	1	2	001000		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													2.00	4.00	6.00						7.00	14.00	21.00						2.00	4.00	5.00																			7.00				7.00							
S5810	040	0		29	10	S5810_040_0	2	5	Specialty Tier	1	2	010010		1	100011111101111000000101				31	60	90	31	60	90	1	31	60	90								10	31		31	14													426.34	25	25	25					426.34	25	25	25					25	25	25																		25			25			25			
S5810	041	0		29	10	S5810_041_0	2	2	Non-Preferred Generic	1	2	000100		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													5.00	10.00	15.00						25.00	50.00	75.00						5.00	10.00	15.00																			25.00				25.00							
S5810	041	0		29	10	S5810_041_0	2	1	Preferred Generic	1	2	001000		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													2.00	4.00	6.00						7.00	14.00	21.00						2.00	4.00	5.00																			7.00				7.00							
S5810	041	0		29	10	S5810_041_0	2	3	Preferred Brand	1	2	000001		2	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14										45.00	90.00	135.00						45.00	90.00	135.00						45.00	90.00	135.00																			45.00							45.00				
S5810	041	0		29	10	S5810_041_0	2	5	Specialty Tier	1	2	010010		1	100011111101111000000101				31	60	90	31	60	90	1	31	60	90								10	31		31	14													292.49	25	25	25					292.49	25	25	25					25	25	25																		25			25			25			
S5810	041	0		29	10	S5810_041_0	2	4	Non-Preferred Brand	1	2	100000		1	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14													92.90	43	43	43					92.90	43	43	43					43	43	43																		43						43			
S5810	042	0		29	10	S5810_042_0	2	5	Specialty Tier	1	2	010010		1	100011111101111000000101				31	60	90	31	60	90	1	31	60	90								10	31		31	14													311.04	25	25	25					311.04	25	25	25					25	25	25																		25			25			25			
S5810	042	0		29	10	S5810_042_0	2	3	Preferred Brand	1	2	000001		2	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14										45.00	90.00	135.00						45.00	90.00	135.00						45.00	90.00	135.00																			45.00							45.00				
S5810	042	0		29	10	S5810_042_0	2	1	Preferred Generic	1	2	001000		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													2.00	4.00	6.00						7.00	14.00	21.00						2.00	4.00	5.00																			7.00				7.00							
S5810	042	0		29	10	S5810_042_0	2	2	Non-Preferred Generic	1	2	000100		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													5.00	10.00	15.00						21.00	42.00	63.00						5.00	10.00	15.00																			21.00				21.00							
S5810	042	0		29	10	S5810_042_0	2	4	Non-Preferred Brand	1	2	100000		1	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14													93.22	39	39	39					93.22	39	39	39					39	39	39																		39						39			
S5810	043	0		29	10	S5810_043_0	2	1	Preferred Generic	1	2	001000		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													2.00	4.00	6.00						7.00	14.00	21.00						2.00	4.00	5.00																			7.00				7.00							
S5810	043	0		29	10	S5810_043_0	2	2	Non-Preferred Generic	1	2	000100		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													5.00	10.00	15.00						29.00	58.00	87.00						5.00	10.00	15.00																			29.00				29.00							
S5810	043	0		29	10	S5810_043_0	2	3	Preferred Brand	1	2	000001		2	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14										45.00	90.00	135.00						45.00	90.00	135.00						45.00	90.00	135.00																			45.00							45.00				
S5810	043	0		29	10	S5810_043_0	2	4	Non-Preferred Brand	1	2	100000		1	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14													93.26	38	38	38					93.26	38	38	38					38	38	38																		38						38			
S5810	043	0		29	10	S5810_043_0	2	5	Specialty Tier	1	2	010010		1	100011111101111000000101				31	60	90	31	60	90	1	31	60	90								10	31		31	14													367.82	25	25	25					367.82	25	25	25					25	25	25																		25			25			25			
S5810	044	0		29	10	S5810_044_0	2	5	Specialty Tier	1	2	010010		1	100011111101111000000101				31	60	90	31	60	90	1	31	60	90								10	31		31	14													375.25	25	25	25					375.25	25	25	25					25	25	25																		25			25			25			
S5810	044	0		29	10	S5810_044_0	2	4	Non-Preferred Brand	1	2	100000		1	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14													93.66	41	41	41					93.66	41	41	41					41	41	41																		41						41			
S5810	044	0		29	10	S5810_044_0	2	3	Preferred Brand	1	2	000001		2	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14										45.00	90.00	135.00						45.00	90.00	135.00						45.00	90.00	135.00																			45.00							45.00				
S5810	044	0		29	10	S5810_044_0	2	2	Non-Preferred Generic	1	2	000100		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													5.00	10.00	15.00						16.00	32.00	48.00						5.00	10.00	15.00																			16.00				16.00							
S5810	044	0		29	10	S5810_044_0	2	1	Preferred Generic	1	2	001000		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													2.00	4.00	6.00						7.00	14.00	21.00						2.00	4.00	5.00																			7.00				7.00							
S5810	045	0		29	10	S5810_045_0	2	5	Specialty Tier	1	2	010010		1	100011111101111000000101				31	60	90	31	60	90	1	31	60	90								10	31		31	14													287.86	25	25	25					287.86	25	25	25					25	25	25																		25			25			25			
S5810	045	0		29	10	S5810_045_0	2	4	Non-Preferred Brand	1	2	100000		1	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14													94.64	50	50	50					94.64	50	50	50					50	50	50																		50						50			
S5810	045	0		29	10	S5810_045_0	2	3	Preferred Brand	1	2	000001		2	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14										45.00	90.00	135.00						45.00	90.00	135.00						45.00	90.00	135.00																			45.00							45.00				
S5810	045	0		29	10	S5810_045_0	2	2	Non-Preferred Generic	1	2	000100		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													5.00	10.00	15.00						33.00	66.00	99.00						5.00	10.00	15.00																			33.00				33.00							
S5810	045	0		29	10	S5810_045_0	2	1	Preferred Generic	1	2	001000		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													2.00	4.00	6.00						7.00	14.00	21.00						2.00	4.00	5.00																			7.00				7.00							
S5810	046	0		29	10	S5810_046_0	1	4	Non-Preferred Brand	1	2	100000		1	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14													94.13	44	44	44					94.13	44	44	44					44	44	44																		44						44			
S5810	046	0		29	10	S5810_046_0	1	3	Preferred Brand	1	2	000001		2	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14										40.00	80.00	120.00						40.00	80.00	120.00						40.00	80.00	120.00																			40.00							40.00				
S5810	046	0		29	10	S5810_046_0	1	2	Non-Preferred Generic	1	2	000100		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													5.00	10.00	15.00						30.00	60.00	90.00						5.00	10.00	15.00																			30.00				30.00							
S5810	046	0		29	10	S5810_046_0	1	1	Preferred Generic	1	2	001000		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													2.00	4.00	6.00						7.00	14.00	21.00						2.00	4.00	5.00																			7.00				7.00							
S5810	046	0		29	10	S5810_046_0	1	5	Specialty Tier	1	2	010010		1	100011111101111000000101				31	60	90	31	60	90	1	31	60	90								10	31		31	14													196.22	25	25	25					196.22	25	25	25					25	25	25																		25			25			25			
S5810	047	0		29	10	S5810_047_0	1	4	Non-Preferred Brand	1	2	100000		1	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14													94.65	36	36	36					94.65	36	36	36					36	36	36																		36						36			
S5810	047	0		29	10	S5810_047_0	1	5	Specialty Tier	1	2	010010		1	100011111101111000000101				31	60	90	31	60	90	1	31	60	90								10	31		31	14													267.26	25	25	25					267.26	25	25	25					25	25	25																		25			25			25			
S5810	047	0		29	10	S5810_047_0	1	3	Preferred Brand	1	2	000001		2	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14										45.00	90.00	135.00						45.00	90.00	135.00						45.00	90.00	135.00																			45.00							45.00				
S5810	047	0		29	10	S5810_047_0	1	1	Preferred Generic	1	2	001000		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													2.00	4.00	6.00						7.00	14.00	21.00						2.00	4.00	5.00																			7.00				7.00							
S5810	047	0		29	10	S5810_047_0	1	2	Non-Preferred Generic	1	2	000100		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													5.00	10.00	15.00						16.00	32.00	48.00						5.00	10.00	15.00																			16.00				16.00							
S5810	048	0		29	10	S5810_048_0	1	3	Preferred Brand	1	2	000001		2	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14										45.00	90.00	135.00						45.00	90.00	135.00						45.00	90.00	135.00																			45.00							45.00				
S5810	048	0		29	10	S5810_048_0	1	4	Non-Preferred Brand	1	2	100000		1	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14													92.97	34	34	34					92.97	34	34	34					34	34	34																		34						34			
S5810	048	0		29	10	S5810_048_0	1	5	Specialty Tier	1	2	010010		1	100011111101111000000101				31	60	90	31	60	90	1	31	60	90								10	31		31	14													315.16	25	25	25					315.16	25	25	25					25	25	25																		25			25			25			
S5810	048	0		29	10	S5810_048_0	1	2	Non-Preferred Generic	1	2	000100		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													5.00	10.00	15.00						24.00	48.00	72.00						5.00	10.00	15.00																			24.00				24.00							
S5810	048	0		29	10	S5810_048_0	1	1	Preferred Generic	1	2	001000		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													2.00	4.00	6.00						7.00	14.00	21.00						2.00	4.00	5.00																			7.00				7.00							
S5810	049	0		29	10	S5810_049_0	1	4	Non-Preferred Brand	1	2	100000		1	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14													94.30	38	38	38					94.30	38	38	38					38	38	38																		38						38			
S5810	049	0		29	10	S5810_049_0	1	3	Preferred Brand	1	2	000001		2	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14										45.00	90.00	135.00						45.00	90.00	135.00						45.00	90.00	135.00																			45.00							45.00				
S5810	049	0		29	10	S5810_049_0	1	2	Non-Preferred Generic	1	2	000100		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													5.00	10.00	15.00						22.00	44.00	66.00						5.00	10.00	15.00																			22.00				22.00							
S5810	049	0		29	10	S5810_049_0	1	1	Preferred Generic	1	2	001000		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													2.00	4.00	6.00						7.00	14.00	21.00						2.00	4.00	5.00																			7.00				7.00							
S5810	049	0		29	10	S5810_049_0	1	5	Specialty Tier	1	2	010010		1	100011111101111000000101				31	60	90	31	60	90	1	31	60	90								10	31		31	14													230.15	25	25	25					230.15	25	25	25					25	25	25																		25			25			25			
S5810	050	0		29	10	S5810_050_0	1	1	Preferred Generic	1	2	001000		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													2.00	4.00	6.00						7.00	14.00	21.00						2.00	4.00	5.00																			7.00				7.00							
S5810	050	0		29	10	S5810_050_0	1	2	Non-Preferred Generic	1	2	000100		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													5.00	10.00	15.00						28.00	56.00	84.00						5.00	10.00	15.00																			28.00				28.00							
S5810	050	0		29	10	S5810_050_0	1	3	Preferred Brand	1	2	000001		2	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14										45.00	90.00	135.00						45.00	90.00	135.00						45.00	90.00	135.00																			45.00							45.00				
S5810	050	0		29	10	S5810_050_0	1	5	Specialty Tier	1	2	010010		1	100011111101111000000101				31	60	90	31	60	90	1	31	60	90								10	31		31	14													184.27	25	25	25					184.27	25	25	25					25	25	25																		25			25			25			
S5810	050	0		29	10	S5810_050_0	1	4	Non-Preferred Brand	1	2	100000		1	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14													93.42	36	36	36					93.42	36	36	36					36	36	36																		36						36			
S5810	051	0		29	10	S5810_051_0	1	1	Preferred Generic	1	2	001000		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													2.00	4.00	6.00						7.00	14.00	21.00						2.00	4.00	5.00																			7.00				7.00							
S5810	051	0		29	10	S5810_051_0	1	2	Non-Preferred Generic	1	2	000100		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													5.00	10.00	15.00						25.00	50.00	75.00						5.00	10.00	15.00																			25.00				25.00							
S5810	051	0		29	10	S5810_051_0	1	4	Non-Preferred Brand	1	2	100000		1	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14													94.25	39	39	39					94.25	39	39	39					39	39	39																		39						39			
S5810	051	0		29	10	S5810_051_0	1	3	Preferred Brand	1	2	000001		2	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14										45.00	90.00	135.00						45.00	90.00	135.00						45.00	90.00	135.00																			45.00							45.00				
S5810	051	0		29	10	S5810_051_0	1	5	Specialty Tier	1	2	010010		1	100011111101111000000101				31	60	90	31	60	90	1	31	60	90								10	31		31	14													312.83	25	25	25					312.83	25	25	25					25	25	25																		25			25			25			
S5810	052	0		29	10	S5810_052_0	1	2	Non-Preferred Generic	1	2	000100		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													5.00	10.00	15.00						28.00	56.00	84.00						5.00	10.00	15.00																			28.00				28.00							
S5810	052	0		29	10	S5810_052_0	1	3	Preferred Brand	1	2	000001		2	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14										40.00	80.00	120.00						40.00	80.00	120.00						40.00	80.00	120.00																			40.00							40.00				
S5810	052	0		29	10	S5810_052_0	1	4	Non-Preferred Brand	1	2	100000		1	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14													94.10	46	46	46					94.10	46	46	46					46	46	46																		46						46			
S5810	052	0		29	10	S5810_052_0	1	5	Specialty Tier	1	2	010010		1	100011111101111000000101				31	60	90	31	60	90	1	31	60	90								10	31		31	14													310.43	25	25	25					310.43	25	25	25					25	25	25																		25			25			25			
S5810	052	0		29	10	S5810_052_0	1	1	Preferred Generic	1	2	001000		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													2.00	4.00	6.00						7.00	14.00	21.00						2.00	4.00	5.00																			7.00				7.00							
S5810	053	0		29	10	S5810_053_0	2	5	Specialty Tier	1	2	010010		1	111100000001111000000101	31	60	90							1	31	60	90								10	31		31	14					366.95	25	25	25																					25	25	25																		25			25			25			
S5810	053	0		29	10	S5810_053_0	2	4	Non-Preferred Brand	1	2	100000		1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					94.82	37	37	37																					37	37	37																		37						37			
S5810	053	0		29	10	S5810_053_0	2	3	Preferred Brand	1	2	000001		2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00				
S5810	053	0		29	10	S5810_053_0	2	1	Preferred Generic	1	2	001000		2	011100000001111000000100	31	60	90							1	31	60	90								10	31					2.00	4.00	6.00																						2.00	4.00	5.00																			2.00				2.00							
S5810	053	0		29	10	S5810_053_0	2	2	Non-Preferred Generic	1	2	000100		2	011100000001111000000100	31	60	90							1	31	60	90								10	31					20.00	40.00	60.00																						20.00	40.00	60.00																			20.00				20.00							
S5810	054	0		29	10	S5810_054_0	1	1	Preferred Generic	1	2	001000		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													2.00	4.00	6.00						7.00	14.00	21.00						2.00	4.00	5.00																			7.00				7.00							
S5810	054	0		29	10	S5810_054_0	1	2	Non-Preferred Generic	1	2	000100		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													5.00	10.00	15.00						21.00	42.00	63.00						5.00	10.00	15.00																			21.00				21.00							
S5810	054	0		29	10	S5810_054_0	1	3	Preferred Brand	1	2	000001		2	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14										45.00	90.00	135.00						45.00	90.00	135.00						45.00	90.00	135.00																			45.00							45.00				
S5810	054	0		29	10	S5810_054_0	1	4	Non-Preferred Brand	1	2	100000		1	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14													94.24	40	40	40					94.24	40	40	40					40	40	40																		40						40			
S5810	054	0		29	10	S5810_054_0	1	5	Specialty Tier	1	2	010010		1	100011111101111000000101				31	60	90	31	60	90	1	31	60	90								10	31		31	14													310.00	25	25	25					310.00	25	25	25					25	25	25																		25			25			25			
S5810	055	0		29	10	S5810_055_0	1	1	Preferred Generic	1	2	001000		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													2.00	4.00	6.00						7.00	14.00	21.00						2.00	4.00	5.00																			7.00				7.00							
S5810	055	0		29	10	S5810_055_0	1	2	Non-Preferred Generic	1	2	000100		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													5.00	10.00	15.00						22.00	44.00	66.00						5.00	10.00	15.00																			22.00				22.00							
S5810	055	0		29	10	S5810_055_0	1	3	Preferred Brand	1	2	000001		2	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14										40.00	80.00	120.00						40.00	80.00	120.00						40.00	80.00	120.00																			40.00							40.00				
S5810	055	0		29	10	S5810_055_0	1	4	Non-Preferred Brand	1	2	100000		1	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14													93.06	47	47	47					93.06	47	47	47					47	47	47																		47						47			
S5810	055	0		29	10	S5810_055_0	1	5	Specialty Tier	1	2	010010		1	100011111101111000000101				31	60	90	31	60	90	1	31	60	90								10	31		31	14													388.80	25	25	25					388.80	25	25	25					25	25	25																		25			25			25			
S5810	056	0		29	10	S5810_056_0	1	4	Non-Preferred Brand	1	2	100000		1	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14													93.98	43	43	43					93.98	43	43	43					43	43	43																		43						43			
S5810	056	0		29	10	S5810_056_0	1	3	Preferred Brand	1	2	000001		2	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14										45.00	90.00	135.00						45.00	90.00	135.00						45.00	90.00	135.00																			45.00							45.00				
S5810	056	0		29	10	S5810_056_0	1	2	Non-Preferred Generic	1	2	000100		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													5.00	10.00	15.00						26.00	52.00	78.00						5.00	10.00	15.00																			26.00				26.00							
S5810	056	0		29	10	S5810_056_0	1	1	Preferred Generic	1	2	001000		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													2.00	4.00	6.00						7.00	14.00	21.00						2.00	4.00	5.00																			7.00				7.00							
S5810	056	0		29	10	S5810_056_0	1	5	Specialty Tier	1	2	010010		1	100011111101111000000101				31	60	90	31	60	90	1	31	60	90								10	31		31	14													362.40	25	25	25					362.40	25	25	25					25	25	25																		25			25			25			
S5810	057	0		29	10	S5810_057_0	1	1	Preferred Generic	1	2	001000		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													2.00	4.00	6.00						7.00	14.00	21.00						2.00	4.00	5.00																			7.00				7.00							
S5810	057	0		29	10	S5810_057_0	1	2	Non-Preferred Generic	1	2	000100		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													5.00	10.00	15.00						24.00	48.00	72.00						5.00	10.00	15.00																			24.00				24.00							
S5810	057	0		29	10	S5810_057_0	1	3	Preferred Brand	1	2	000001		2	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14										45.00	90.00	135.00						45.00	90.00	135.00						45.00	90.00	135.00																			45.00							45.00				
S5810	057	0		29	10	S5810_057_0	1	4	Non-Preferred Brand	1	2	100000		1	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14													94.92	40	40	40					94.92	40	40	40					40	40	40																		40						40			
S5810	057	0		29	10	S5810_057_0	1	5	Specialty Tier	1	2	010010		1	100011111101111000000101				31	60	90	31	60	90	1	31	60	90								10	31		31	14													282.04	25	25	25					282.04	25	25	25					25	25	25																		25			25			25			
S5810	058	0		29	10	S5810_058_0	1	1	Preferred Generic	1	2	001000		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													2.00	4.00	6.00						7.00	14.00	21.00						2.00	4.00	5.00																			7.00				7.00							
S5810	058	0		29	10	S5810_058_0	1	2	Non-Preferred Generic	1	2	000100		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													5.00	10.00	15.00						27.00	54.00	81.00						5.00	10.00	15.00																			27.00				27.00							
S5810	058	0		29	10	S5810_058_0	1	3	Preferred Brand	1	2	000001		2	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14										45.00	90.00	135.00						45.00	90.00	135.00						45.00	90.00	135.00																			45.00							45.00				
S5810	058	0		29	10	S5810_058_0	1	4	Non-Preferred Brand	1	2	100000		1	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14													93.79	35	35	35					93.79	35	35	35					35	35	35																		35						35			
S5810	058	0		29	10	S5810_058_0	1	5	Specialty Tier	1	2	010010		1	100011111101111000000101				31	60	90	31	60	90	1	31	60	90								10	31		31	14													214.06	25	25	25					214.06	25	25	25					25	25	25																		25			25			25			
S5810	059	0		29	10	S5810_059_0	1	5	Specialty Tier	1	2	010010		1	100011111101111000000101				31	60	90	31	60	90	1	31	60	90								10	31		31	14													226.76	25	25	25					226.76	25	25	25					25	25	25																		25			25			25			
S5810	059	0		29	10	S5810_059_0	1	4	Non-Preferred Brand	1	2	100000		1	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14													94.28	36	36	36					94.28	36	36	36					36	36	36																		36						36			
S5810	059	0		29	10	S5810_059_0	1	3	Preferred Brand	1	2	000001		2	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14										45.00	90.00	135.00						45.00	90.00	135.00						45.00	90.00	135.00																			45.00							45.00				
S5810	059	0		29	10	S5810_059_0	1	2	Non-Preferred Generic	1	2	000100		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													5.00	10.00	15.00						25.00	50.00	75.00						5.00	10.00	15.00																			25.00				25.00							
S5810	059	0		29	10	S5810_059_0	1	1	Preferred Generic	1	2	001000		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													2.00	4.00	6.00						7.00	14.00	21.00						2.00	4.00	5.00																			7.00				7.00							
S5810	060	0		29	10	S5810_060_0	1	2	Non-Preferred Generic	1	2	000100		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													5.00	10.00	15.00						31.00	62.00	93.00						5.00	10.00	15.00																			31.00				31.00							
S5810	060	0		29	10	S5810_060_0	1	1	Preferred Generic	1	2	001000		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													2.00	4.00	6.00						7.00	14.00	21.00						2.00	4.00	5.00																			7.00				7.00							
S5810	060	0		29	10	S5810_060_0	1	3	Preferred Brand	1	2	000001		2	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14										40.00	80.00	120.00						40.00	80.00	120.00						40.00	80.00	120.00																			40.00							40.00				
S5810	060	0		29	10	S5810_060_0	1	4	Non-Preferred Brand	1	2	100000		1	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14													94.58	49	49	49					94.58	49	49	49					49	49	49																		49						49			
S5810	060	0		29	10	S5810_060_0	1	5	Specialty Tier	1	2	010010		1	100011111101111000000101				31	60	90	31	60	90	1	31	60	90								10	31		31	14													207.67	25	25	25					207.67	25	25	25					25	25	25																		25			25			25			
S5810	061	0		29	10	S5810_061_0	1	5	Specialty Tier	1	2	010010		1	111100000001111000000101	31	60	90							1	31	60	90								10	31		31	14					318.45	25	25	25																					25	25	25																		25			25			25			
S5810	061	0		29	10	S5810_061_0	1	4	Non-Preferred Brand	1	2	100000		1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					93.83	42	42	42																					42	42	42																		42						42			
S5810	061	0		29	10	S5810_061_0	1	3	Preferred Brand	1	2	000001		2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00				
S5810	061	0		29	10	S5810_061_0	1	2	Non-Preferred Generic	1	2	000100		2	011100000001111000000100	31	60	90							1	31	60	90								10	31					22.00	44.00	66.00																						22.00	44.00	66.00																			22.00				22.00							
S5810	061	0		29	10	S5810_061_0	1	1	Preferred Generic	1	2	001000		2	011100000001111000000100	31	60	90							1	31	60	90								10	31					2.00	4.00	6.00																						2.00	4.00	5.00																			2.00				2.00							
S5810	062	0		29	10	S5810_062_0	1	5	Specialty Tier	1	2	010010		1	100011111101111000000101				31	60	90	31	60	90	1	31	60	90								10	31		31	14													283.13	25	25	25					283.13	25	25	25					25	25	25																		25			25			25			
S5810	062	0		29	10	S5810_062_0	1	4	Non-Preferred Brand	1	2	100000		1	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14													92.57	50	50	50					92.57	50	50	50					50	50	50																		50						50			
S5810	062	0		29	10	S5810_062_0	1	3	Preferred Brand	1	2	000001		2	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14										40.00	80.00	120.00						40.00	80.00	120.00						40.00	80.00	120.00																			40.00							40.00				
S5810	062	0		29	10	S5810_062_0	1	2	Non-Preferred Generic	1	2	000100		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													5.00	10.00	15.00						28.00	56.00	84.00						5.00	10.00	15.00																			28.00				28.00							
S5810	062	0		29	10	S5810_062_0	1	1	Preferred Generic	1	2	001000		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													2.00	4.00	6.00						7.00	14.00	21.00						2.00	4.00	5.00																			7.00				7.00							
S5810	063	0		29	10	S5810_063_0	1	2	Non-Preferred Generic	1	2	000100		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													5.00	10.00	15.00						33.00	66.00	99.00						5.00	10.00	15.00																			33.00				33.00							
S5810	063	0		29	10	S5810_063_0	1	1	Preferred Generic	1	2	001000		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													2.00	4.00	6.00						7.00	14.00	21.00						2.00	4.00	5.00																			7.00				7.00							
S5810	063	0		29	10	S5810_063_0	1	5	Specialty Tier	1	2	010010		1	100011111101111000000101				31	60	90	31	60	90	1	31	60	90								10	31		31	14													262.98	25	25	25					262.98	25	25	25					25	25	25																		25			25			25			
S5810	063	0		29	10	S5810_063_0	1	4	Non-Preferred Brand	1	2	100000		1	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14													94.03	48	48	48					94.03	48	48	48					48	48	48																		48						48			
S5810	063	0		29	10	S5810_063_0	1	3	Preferred Brand	1	2	000001		2	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14										40.00	80.00	120.00						40.00	80.00	120.00						40.00	80.00	120.00																			40.00							40.00				
S5810	064	0		29	10	S5810_064_0	1	5	Specialty Tier	1	2	010010		1	111100000001111000000101	31	60	90							1	31	60	90								10	31		31	14					253.44	25	25	25																					25	25	25																		25			25			25			
S5810	064	0		29	10	S5810_064_0	1	1	Preferred Generic	1	2	001000		2	011100000001111000000100	31	60	90							1	31	60	90								10	31					2.00	4.00	6.00																						2.00	4.00	5.00																			2.00				2.00							
S5810	064	0		29	10	S5810_064_0	1	2	Non-Preferred Generic	1	2	000100		2	011100000001111000000100	31	60	90							1	31	60	90								10	31					21.00	42.00	63.00																						21.00	42.00	63.00																			21.00				21.00							
S5810	064	0		29	10	S5810_064_0	1	4	Non-Preferred Brand	1	2	100000		1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					93.30	38	38	38																					38	38	38																		38						38			
S5810	064	0		29	10	S5810_064_0	1	3	Preferred Brand	1	2	000001		2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00				
S5810	065	0		29	10	S5810_065_0	1	1	Preferred Generic	1	2	001000		2	011100000001111000000100	31	60	90							1	31	60	90								10	31					2.00	4.00	6.00																						2.00	4.00	5.00																			2.00				2.00							
S5810	065	0		29	10	S5810_065_0	1	3	Preferred Brand	1	2	000001		2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00				
S5810	065	0		29	10	S5810_065_0	1	4	Non-Preferred Brand	1	2	100000		1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					94.20	41	41	41																					41	41	41																		41						41			
S5810	065	0		29	10	S5810_065_0	1	5	Specialty Tier	1	2	010010		1	111100000001111000000101	31	60	90							1	31	60	90								10	31		31	14					262.04	25	25	25																					25	25	25																		25			25			25			
S5810	065	0		29	10	S5810_065_0	1	2	Non-Preferred Generic	1	2	000100		2	011100000001111000000100	31	60	90							1	31	60	90								10	31					23.00	46.00	69.00																						23.00	46.00	69.00																			23.00				23.00							
S5810	066	0		29	10	S5810_066_0	1	1	Preferred Generic	1	2	001000		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													2.00	4.00	6.00						10.00	20.00	30.00						2.00	4.00	5.00																			10.00				10.00							
S5810	066	0		29	10	S5810_066_0	1	3	Preferred Brand	1	2	000001		2	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14										45.00	90.00	135.00						45.00	90.00	135.00						45.00	90.00	135.00																			45.00							45.00				
S5810	066	0		29	10	S5810_066_0	1	2	Non-Preferred Generic	1	2	000100		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													5.00	10.00	15.00						33.00	66.00	99.00						5.00	10.00	15.00																			33.00				33.00							
S5810	066	0		29	10	S5810_066_0	1	5	Specialty Tier	1	2	010010		1	100011111101111000000101				31	60	90	31	60	90	1	31	60	90								10	31		31	14													346.59	25	25	25					346.59	25	25	25					25	25	25																		25			25			25			
S5810	066	0		29	10	S5810_066_0	1	4	Non-Preferred Brand	1	2	100000		1	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14													94.41	47	47	47					94.41	47	47	47					47	47	47																		47						47			
S5810	067	0		29	10	S5810_067_0	1	2	Non-Preferred Generic	1	2	000100		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													5.00	10.00	15.00						18.00	36.00	54.00						5.00	10.00	15.00																			18.00				18.00							
S5810	067	0		29	10	S5810_067_0	1	1	Preferred Generic	1	2	001000		2	000011111101111000000100				31	60	90	31	60	90	1	31	60	90								10	31													2.00	4.00	6.00						7.00	14.00	21.00						2.00	4.00	5.00																			7.00				7.00							
S5810	067	0		29	10	S5810_067_0	1	5	Specialty Tier	1	2	010010		1	100011111101111000000101				31	60	90	31	60	90	1	31	60	90								10	31		31	14													397.45	25	25	25					397.45	25	25	25					25	25	25																		25			25			25			
S5810	067	0		29	10	S5810_067_0	1	3	Preferred Brand	1	2	000001		2	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14										45.00	90.00	135.00						45.00	90.00	135.00						45.00	90.00	135.00																			45.00							45.00				
S5810	067	0		29	10	S5810_067_0	1	4	Non-Preferred Brand	1	2	100000		1	100011111101111000000001				31	60	90	31	60	90	1	31	60	90								10			31	14													94.70	44	44	44					94.70	44	44	44					44	44	44																		44						44			
S5810	068	0		29	10	S5810_068_0	1	3	Preferred Brand	1	2	000001		2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00				
S5810	068	0		29	10	S5810_068_0	1	5	Specialty Tier	1	2	010010		1	111100000001111000000101	31	60	90							1	31	60	90								10	31		31	14					303.68	25	25	25																					25	25	25																		25			25			25			
S5810	068	0		29	10	S5810_068_0	1	4	Non-Preferred Brand	1	2	100000		1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					94.44	47	47	47																					47	47	47																		47						47			
S5810	068	0		29	10	S5810_068_0	1	1	Preferred Generic	1	2	001000		2	011100000001111000000100	31	60	90							1	31	60	90								10	31					2.00	4.00	6.00																						2.00	4.00	5.00																			2.00				2.00							
S5810	068	0		29	10	S5810_068_0	1	2	Non-Preferred Generic	1	2	000100		2	011100000001111000000100	31	60	90							1	31	60	90								10	31					7.00	14.00	21.00																						7.00	14.00	21.00																			7.00				7.00							
S5810	171	0		29	10	S5810_171_0	2	1	Preferred Generic	1	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00							
S5810	171	0		29	10	S5810_171_0	2	2	Non-Preferred Generic	1	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00							
S5810	171	0		29	10	S5810_171_0	2	3	Preferred Brand	1	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00				
S5810	171	0		29	10	S5810_171_0	2	4	Non-Preferred Brand	1	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					94.85	46	46	46																					46	46	46																		46						46			
S5810	171	0		29	10	S5810_171_0	2	4	Non-Preferred Brand	3	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					94.85	46	46	46																					46	46	46																		46						46	2		
S5810	171	0		29	10	S5810_171_0	2	1	Preferred Generic	3	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00					1		
S5810	171	0		29	10	S5810_171_0	2	2	Non-Preferred Generic	3	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00					1		
S5810	171	0		29	10	S5810_171_0	2	3	Preferred Brand	3	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00		2		
S5810	171	0		29	10	S5810_171_0	2	5	Specialty Tier	1	4	010010	1	1	111100000001111000000101	31	60	90							1	31	60	90								10	31		31	14					294.30	33	33	33																					33	33	33																		33			33			33			
S5810	172	0		29	10	S5810_172_0	1	5	Specialty Tier	1	4	010010	1	1	111100000001111000000101	31	60	90							1	31	60	90								10	31		31	14					338.95	33	33	33																					33	33	33																		33			33			33			
S5810	172	0		29	10	S5810_172_0	1	2	Non-Preferred Generic	3	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00					1		
S5810	172	0		29	10	S5810_172_0	1	1	Preferred Generic	3	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00					1		
S5810	172	0		29	10	S5810_172_0	1	4	Non-Preferred Brand	1	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					92.72	37	37	37																					37	37	37																		37						37			
S5810	172	0		29	10	S5810_172_0	1	3	Preferred Brand	1	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00				
S5810	172	0		29	10	S5810_172_0	1	2	Non-Preferred Generic	1	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00							
S5810	172	0		29	10	S5810_172_0	1	1	Preferred Generic	1	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00							
S5810	172	0		29	10	S5810_172_0	1	4	Non-Preferred Brand	3	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					92.72	37	37	37																					37	37	37																		37						37	2		
S5810	172	0		29	10	S5810_172_0	1	3	Preferred Brand	3	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00		2		
S5810	174	0		29	10	S5810_174_0	1	1	Preferred Generic	1	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00							
S5810	174	0		29	10	S5810_174_0	1	2	Non-Preferred Generic	1	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00							
S5810	174	0		29	10	S5810_174_0	1	3	Preferred Brand	1	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00				
S5810	174	0		29	10	S5810_174_0	1	4	Non-Preferred Brand	1	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					93.13	40	40	40																					40	40	40																		40						40			
S5810	174	0		29	10	S5810_174_0	1	2	Non-Preferred Generic	3	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00					1		
S5810	174	0		29	10	S5810_174_0	1	1	Preferred Generic	3	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00					1		
S5810	174	0		29	10	S5810_174_0	1	4	Non-Preferred Brand	3	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					93.13	40	40	40																					40	40	40																		40						40	2		
S5810	174	0		29	10	S5810_174_0	1	3	Preferred Brand	3	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00		2		
S5810	174	0		29	10	S5810_174_0	1	5	Specialty Tier	1	4	010010	1	1	111100000001111000000101	31	60	90							1	31	60	90								10	31		31	14					302.54	33	33	33																					33	33	33																		33			33			33			
S5810	175	0		29	10	S5810_175_0	1	1	Preferred Generic	1	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00							
S5810	175	0		29	10	S5810_175_0	1	2	Non-Preferred Generic	1	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00							
S5810	175	0		29	10	S5810_175_0	1	3	Preferred Brand	1	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00				
S5810	175	0		29	10	S5810_175_0	1	4	Non-Preferred Brand	1	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					92.78	39	39	39																					39	39	39																		39						39			
S5810	175	0		29	10	S5810_175_0	1	5	Specialty Tier	1	4	010010	1	1	111100000001111000000101	31	60	90							1	31	60	90								10	31		31	14					274.32	33	33	33																					33	33	33																		33			33			33			
S5810	175	0		29	10	S5810_175_0	1	2	Non-Preferred Generic	3	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00					1		
S5810	175	0		29	10	S5810_175_0	1	1	Preferred Generic	3	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00					1		
S5810	175	0		29	10	S5810_175_0	1	3	Preferred Brand	3	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00		2		
S5810	175	0		29	10	S5810_175_0	1	4	Non-Preferred Brand	3	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					92.78	39	39	39																					39	39	39																		39						39	2		
S5810	176	0		29	10	S5810_176_0	1	2	Non-Preferred Generic	3	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00					1		
S5810	176	0		29	10	S5810_176_0	1	4	Non-Preferred Brand	3	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					94.23	44	44	44																					44	44	44																		44						44	2		
S5810	176	0		29	10	S5810_176_0	1	1	Preferred Generic	3	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00					1		
S5810	176	0		29	10	S5810_176_0	1	5	Specialty Tier	1	4	010010	1	1	111100000001111000000101	31	60	90							1	31	60	90								10	31		31	14					257.44	33	33	33																					33	33	33																		33			33			33			
S5810	176	0		29	10	S5810_176_0	1	3	Preferred Brand	3	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00		2		
S5810	176	0		29	10	S5810_176_0	1	3	Preferred Brand	1	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00				
S5810	176	0		29	10	S5810_176_0	1	1	Preferred Generic	1	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00							
S5810	176	0		29	10	S5810_176_0	1	2	Non-Preferred Generic	1	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00							
S5810	176	0		29	10	S5810_176_0	1	4	Non-Preferred Brand	1	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					94.23	44	44	44																					44	44	44																		44						44			
S5810	177	0		29	10	S5810_177_0	1	2	Non-Preferred Generic	1	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00							
S5810	177	0		29	10	S5810_177_0	1	1	Preferred Generic	1	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00							
S5810	177	0		29	10	S5810_177_0	1	4	Non-Preferred Brand	3	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					93.50	45	45	45																					45	45	45																		45						45	2		
S5810	177	0		29	10	S5810_177_0	1	3	Preferred Brand	3	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00		2		
S5810	177	0		29	10	S5810_177_0	1	2	Non-Preferred Generic	3	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00					1		
S5810	177	0		29	10	S5810_177_0	1	1	Preferred Generic	3	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00					1		
S5810	177	0		29	10	S5810_177_0	1	4	Non-Preferred Brand	1	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					93.50	45	45	45																					45	45	45																		45						45			
S5810	177	0		29	10	S5810_177_0	1	5	Specialty Tier	1	4	010010	1	1	111100000001111000000101	31	60	90							1	31	60	90								10	31		31	14					212.85	33	33	33																					33	33	33																		33			33			33			
S5810	177	0		29	10	S5810_177_0	1	3	Preferred Brand	1	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00				
S5810	178	0		29	10	S5810_178_0	1	2	Non-Preferred Generic	1	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00							
S5810	178	0		29	10	S5810_178_0	1	3	Preferred Brand	3	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00		2		
S5810	178	0		29	10	S5810_178_0	1	2	Non-Preferred Generic	3	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00					1		
S5810	178	0		29	10	S5810_178_0	1	1	Preferred Generic	3	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00					1		
S5810	178	0		29	10	S5810_178_0	1	4	Non-Preferred Brand	3	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					89.32	43	43	43																					43	43	43																		43						43	2		
S5810	178	0		29	10	S5810_178_0	1	4	Non-Preferred Brand	1	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					89.32	43	43	43																					43	43	43																		43						43			
S5810	178	0		29	10	S5810_178_0	1	3	Preferred Brand	1	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00				
S5810	178	0		29	10	S5810_178_0	1	1	Preferred Generic	1	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00							
S5810	178	0		29	10	S5810_178_0	1	5	Specialty Tier	1	4	010010	1	1	111100000001111000000101	31	60	90							1	31	60	90								10	31		31	14					384.09	33	33	33																					33	33	33																		33			33			33			
S5810	179	0		29	10	S5810_179_0	1	2	Non-Preferred Generic	1	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00							
S5810	179	0		29	10	S5810_179_0	1	3	Preferred Brand	1	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00				
S5810	179	0		29	10	S5810_179_0	1	4	Non-Preferred Brand	1	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					82.36	42	42	42																					42	42	42																		42						42			
S5810	179	0		29	10	S5810_179_0	1	5	Specialty Tier	1	4	010010	1	1	111100000001111000000101	31	60	90							1	31	60	90								10	31		31	14					360.94	33	33	33																					33	33	33																		33			33			33			
S5810	179	0		29	10	S5810_179_0	1	1	Preferred Generic	3	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00					1		
S5810	179	0		29	10	S5810_179_0	1	2	Non-Preferred Generic	3	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00					1		
S5810	179	0		29	10	S5810_179_0	1	3	Preferred Brand	3	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00		2		
S5810	179	0		29	10	S5810_179_0	1	4	Non-Preferred Brand	3	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					82.36	42	42	42																					42	42	42																		42						42	2		
S5810	179	0		29	10	S5810_179_0	1	1	Preferred Generic	1	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00							
S5810	180	0		29	10	S5810_180_0	1	3	Preferred Brand	1	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00				
S5810	180	0		29	10	S5810_180_0	1	4	Non-Preferred Brand	1	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					87.38	45	45	45																					45	45	45																		45						45			
S5810	180	0		29	10	S5810_180_0	1	5	Specialty Tier	1	4	010010	1	1	111100000001111000000101	31	60	90							1	31	60	90								10	31		31	14					340.91	33	33	33																					33	33	33																		33			33			33			
S5810	180	0		29	10	S5810_180_0	1	1	Preferred Generic	3	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00					1		
S5810	180	0		29	10	S5810_180_0	1	2	Non-Preferred Generic	3	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00					1		
S5810	180	0		29	10	S5810_180_0	1	3	Preferred Brand	3	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00		2		
S5810	180	0		29	10	S5810_180_0	1	4	Non-Preferred Brand	3	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					87.38	45	45	45																					45	45	45																		45						45	2		
S5810	180	0		29	10	S5810_180_0	1	1	Preferred Generic	1	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00							
S5810	180	0		29	10	S5810_180_0	1	2	Non-Preferred Generic	1	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00							
S5810	182	0		29	10	S5810_182_0	1	3	Preferred Brand	3	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00		2		
S5810	182	0		29	10	S5810_182_0	1	2	Non-Preferred Generic	3	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00					1		
S5810	182	0		29	10	S5810_182_0	1	1	Preferred Generic	3	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00					1		
S5810	182	0		29	10	S5810_182_0	1	5	Specialty Tier	1	4	010010	1	1	111100000001111000000101	31	60	90							1	31	60	90								10	31		31	14					139.23	33	33	33																					33	33	33																		33			33			33			
S5810	182	0		29	10	S5810_182_0	1	4	Non-Preferred Brand	3	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					93.72	42	42	42																					42	42	42																		42						42	2		
S5810	182	0		29	10	S5810_182_0	1	3	Preferred Brand	1	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00				
S5810	182	0		29	10	S5810_182_0	1	2	Non-Preferred Generic	1	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00							
S5810	182	0		29	10	S5810_182_0	1	1	Preferred Generic	1	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00							
S5810	182	0		29	10	S5810_182_0	1	4	Non-Preferred Brand	1	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					93.72	42	42	42																					42	42	42																		42						42			
S5810	183	0		29	10	S5810_183_0	1	4	Non-Preferred Brand	3	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					94.36	41	41	41																					41	41	41																		41						41	2		
S5810	183	0		29	10	S5810_183_0	1	3	Preferred Brand	3	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00		2		
S5810	183	0		29	10	S5810_183_0	1	2	Non-Preferred Generic	3	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00					1		
S5810	183	0		29	10	S5810_183_0	1	1	Preferred Generic	3	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00					1		
S5810	183	0		29	10	S5810_183_0	1	5	Specialty Tier	1	4	010010	1	1	111100000001111000000101	31	60	90							1	31	60	90								10	31		31	14					342.78	33	33	33																					33	33	33																		33			33			33			
S5810	183	0		29	10	S5810_183_0	1	4	Non-Preferred Brand	1	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					94.36	41	41	41																					41	41	41																		41						41			
S5810	183	0		29	10	S5810_183_0	1	3	Preferred Brand	1	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00				
S5810	183	0		29	10	S5810_183_0	1	1	Preferred Generic	1	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00							
S5810	183	0		29	10	S5810_183_0	1	2	Non-Preferred Generic	1	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00							
S5810	184	0		29	10	S5810_184_0	1	2	Non-Preferred Generic	1	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00							
S5810	184	0		29	10	S5810_184_0	1	3	Preferred Brand	1	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00				
S5810	184	0		29	10	S5810_184_0	1	4	Non-Preferred Brand	1	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					87.45	39	39	39																					39	39	39																		39						39			
S5810	184	0		29	10	S5810_184_0	1	5	Specialty Tier	1	4	010010	1	1	111100000001111000000101	31	60	90							1	31	60	90								10	31		31	14					238.26	33	33	33																					33	33	33																		33			33			33			
S5810	184	0		29	10	S5810_184_0	1	1	Preferred Generic	3	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00					1		
S5810	184	0		29	10	S5810_184_0	1	2	Non-Preferred Generic	3	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00					1		
S5810	184	0		29	10	S5810_184_0	1	3	Preferred Brand	3	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00		2		
S5810	184	0		29	10	S5810_184_0	1	4	Non-Preferred Brand	3	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					87.45	39	39	39																					39	39	39																		39						39	2		
S5810	184	0		29	10	S5810_184_0	1	1	Preferred Generic	1	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00							
S5810	185	0		29	10	S5810_185_0	1	2	Non-Preferred Generic	1	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00							
S5810	185	0		29	10	S5810_185_0	1	3	Preferred Brand	1	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00				
S5810	185	0		29	10	S5810_185_0	1	4	Non-Preferred Brand	1	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					87.70	42	42	42																					42	42	42																		42						42			
S5810	185	0		29	10	S5810_185_0	1	5	Specialty Tier	1	4	010010	1	1	111100000001111000000101	31	60	90							1	31	60	90								10	31		31	14					268.68	33	33	33																					33	33	33																		33			33			33			
S5810	185	0		29	10	S5810_185_0	1	1	Preferred Generic	1	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00							
S5810	185	0		29	10	S5810_185_0	1	2	Non-Preferred Generic	3	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00					1		
S5810	185	0		29	10	S5810_185_0	1	3	Preferred Brand	3	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00		2		
S5810	185	0		29	10	S5810_185_0	1	4	Non-Preferred Brand	3	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					87.70	42	42	42																					42	42	42																		42						42	2		
S5810	185	0		29	10	S5810_185_0	1	1	Preferred Generic	3	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00					1		
S5810	186	0		29	10	S5810_186_0	1	4	Non-Preferred Brand	3	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					92.71	41	41	41																					41	41	41																		41						41	2		
S5810	186	0		29	10	S5810_186_0	1	3	Preferred Brand	3	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00		2		
S5810	186	0		29	10	S5810_186_0	1	2	Non-Preferred Generic	3	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00					1		
S5810	186	0		29	10	S5810_186_0	1	1	Preferred Generic	3	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00					1		
S5810	186	0		29	10	S5810_186_0	1	5	Specialty Tier	1	4	010010	1	1	111100000001111000000101	31	60	90							1	31	60	90								10	31		31	14					250.96	33	33	33																					33	33	33																		33			33			33			
S5810	186	0		29	10	S5810_186_0	1	4	Non-Preferred Brand	1	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					92.71	41	41	41																					41	41	41																		41						41			
S5810	186	0		29	10	S5810_186_0	1	3	Preferred Brand	1	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00				
S5810	186	0		29	10	S5810_186_0	1	1	Preferred Generic	1	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00							
S5810	186	0		29	10	S5810_186_0	1	2	Non-Preferred Generic	1	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00							
S5810	187	0		29	10	S5810_187_0	1	2	Non-Preferred Generic	1	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00							
S5810	187	0		29	10	S5810_187_0	1	1	Preferred Generic	1	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00							
S5810	187	0		29	10	S5810_187_0	1	4	Non-Preferred Brand	3	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					90.24	43	43	43																					43	43	43																		43						43	2		
S5810	187	0		29	10	S5810_187_0	1	3	Preferred Brand	3	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00		2		
S5810	187	0		29	10	S5810_187_0	1	2	Non-Preferred Generic	3	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00					1		
S5810	187	0		29	10	S5810_187_0	1	1	Preferred Generic	3	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00					1		
S5810	187	0		29	10	S5810_187_0	1	5	Specialty Tier	1	4	010010	1	1	111100000001111000000101	31	60	90							1	31	60	90								10	31		31	14					269.41	33	33	33																					33	33	33																		33			33			33			
S5810	187	0		29	10	S5810_187_0	1	4	Non-Preferred Brand	1	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					90.24	43	43	43																					43	43	43																		43						43			
S5810	187	0		29	10	S5810_187_0	1	3	Preferred Brand	1	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00				
S5810	188	0		29	10	S5810_188_0	1	1	Preferred Generic	1	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00							
S5810	188	0		29	10	S5810_188_0	1	2	Non-Preferred Generic	1	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00							
S5810	188	0		29	10	S5810_188_0	1	4	Non-Preferred Brand	1	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					94.40	47	47	47																					47	47	47																		47						47			
S5810	188	0		29	10	S5810_188_0	1	5	Specialty Tier	1	4	010010	1	1	111100000001111000000101	31	60	90							1	31	60	90								10	31		31	14					320.12	33	33	33																					33	33	33																		33			33			33			
S5810	188	0		29	10	S5810_188_0	1	3	Preferred Brand	1	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00				
S5810	188	0		29	10	S5810_188_0	1	2	Non-Preferred Generic	3	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00					1		
S5810	188	0		29	10	S5810_188_0	1	3	Preferred Brand	3	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00		2		
S5810	188	0		29	10	S5810_188_0	1	4	Non-Preferred Brand	3	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					94.40	47	47	47																					47	47	47																		47						47	2		
S5810	188	0		29	10	S5810_188_0	1	1	Preferred Generic	3	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00					1		
S5810	189	0		29	10	S5810_189_0	1	2	Non-Preferred Generic	1	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00							
S5810	189	0		29	10	S5810_189_0	1	1	Preferred Generic	1	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00							
S5810	189	0		29	10	S5810_189_0	1	3	Preferred Brand	1	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00				
S5810	189	0		29	10	S5810_189_0	1	4	Non-Preferred Brand	1	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					92.91	41	41	41																					41	41	41																		41						41			
S5810	189	0		29	10	S5810_189_0	1	5	Specialty Tier	1	4	010010	1	1	111100000001111000000101	31	60	90							1	31	60	90								10	31		31	14					538.24	33	33	33																					33	33	33																		33			33			33			
S5810	189	0		29	10	S5810_189_0	1	1	Preferred Generic	3	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00					1		
S5810	189	0		29	10	S5810_189_0	1	4	Non-Preferred Brand	3	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					92.91	41	41	41																					41	41	41																		41						41	2		
S5810	189	0		29	10	S5810_189_0	1	3	Preferred Brand	3	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00		2		
S5810	189	0		29	10	S5810_189_0	1	2	Non-Preferred Generic	3	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00					1		
S5810	190	0		29	10	S5810_190_0	1	4	Non-Preferred Brand	1	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					83.22	44	44	44																					44	44	44																		44						44			
S5810	190	0		29	10	S5810_190_0	1	3	Preferred Brand	1	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00				
S5810	190	0		29	10	S5810_190_0	1	2	Non-Preferred Generic	1	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00							
S5810	190	0		29	10	S5810_190_0	1	1	Preferred Generic	1	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00							
S5810	190	0		29	10	S5810_190_0	1	4	Non-Preferred Brand	3	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					83.22	44	44	44																					44	44	44																		44						44	2		
S5810	190	0		29	10	S5810_190_0	1	1	Preferred Generic	3	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00					1		
S5810	190	0		29	10	S5810_190_0	1	2	Non-Preferred Generic	3	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00					1		
S5810	190	0		29	10	S5810_190_0	1	3	Preferred Brand	3	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00		2		
S5810	190	0		29	10	S5810_190_0	1	5	Specialty Tier	1	4	010010	1	1	111100000001111000000101	31	60	90							1	31	60	90								10	31		31	14					488.02	33	33	33																					33	33	33																		33			33			33			
S5810	191	0		29	10	S5810_191_0	1	4	Non-Preferred Brand	1	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					88.76	46	46	46																					46	46	46																		46						46			
S5810	191	0		29	10	S5810_191_0	1	3	Preferred Brand	1	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00				
S5810	191	0		29	10	S5810_191_0	1	2	Non-Preferred Generic	1	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00							
S5810	191	0		29	10	S5810_191_0	1	1	Preferred Generic	1	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00							
S5810	191	0		29	10	S5810_191_0	1	5	Specialty Tier	1	4	010010	1	1	111100000001111000000101	31	60	90							1	31	60	90								10	31		31	14					302.42	33	33	33																					33	33	33																		33			33			33			
S5810	191	0		29	10	S5810_191_0	1	4	Non-Preferred Brand	3	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					88.76	46	46	46																					46	46	46																		46						46	2		
S5810	191	0		29	10	S5810_191_0	1	3	Preferred Brand	3	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00		2		
S5810	191	0		29	10	S5810_191_0	1	2	Non-Preferred Generic	3	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00					1		
S5810	191	0		29	10	S5810_191_0	1	1	Preferred Generic	3	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00					1		
S5810	192	0		29	10	S5810_192_0	1	1	Preferred Generic	1	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00							
S5810	192	0		29	10	S5810_192_0	1	2	Non-Preferred Generic	1	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00							
S5810	192	0		29	10	S5810_192_0	1	3	Preferred Brand	1	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00				
S5810	192	0		29	10	S5810_192_0	1	4	Non-Preferred Brand	1	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					84.74	46	46	46																					46	46	46																		46						46			
S5810	192	0		29	10	S5810_192_0	1	4	Non-Preferred Brand	3	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					84.74	46	46	46																					46	46	46																		46						46	2		
S5810	192	0		29	10	S5810_192_0	1	2	Non-Preferred Generic	3	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00					1		
S5810	192	0		29	10	S5810_192_0	1	1	Preferred Generic	3	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00					1		
S5810	192	0		29	10	S5810_192_0	1	5	Specialty Tier	1	4	010010	1	1	111100000001111000000101	31	60	90							1	31	60	90								10	31		31	14					365.93	33	33	33																					33	33	33																		33			33			33			
S5810	192	0		29	10	S5810_192_0	1	3	Preferred Brand	3	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00		2		
S5810	193	0		29	10	S5810_193_0	1	1	Preferred Generic	1	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00							
S5810	193	0		29	10	S5810_193_0	1	2	Non-Preferred Generic	1	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00							
S5810	193	0		29	10	S5810_193_0	1	3	Preferred Brand	1	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00				
S5810	193	0		29	10	S5810_193_0	1	4	Non-Preferred Brand	1	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					87.14	44	44	44																					44	44	44																		44						44			
S5810	193	0		29	10	S5810_193_0	1	5	Specialty Tier	1	4	010010	1	1	111100000001111000000101	31	60	90							1	31	60	90								10	31		31	14					175.07	33	33	33																					33	33	33																		33			33			33			
S5810	193	0		29	10	S5810_193_0	1	1	Preferred Generic	3	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00					1		
S5810	193	0		29	10	S5810_193_0	1	2	Non-Preferred Generic	3	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00					1		
S5810	193	0		29	10	S5810_193_0	1	3	Preferred Brand	3	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00		2		
S5810	193	0		29	10	S5810_193_0	1	4	Non-Preferred Brand	3	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					87.14	44	44	44																					44	44	44																		44						44	2		
S5810	194	0		29	10	S5810_194_0	1	2	Non-Preferred Generic	1	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00							
S5810	194	0		29	10	S5810_194_0	1	3	Preferred Brand	1	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00				
S5810	194	0		29	10	S5810_194_0	1	4	Non-Preferred Brand	1	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					76.61	40	40	40																					40	40	40																		40						40			
S5810	194	0		29	10	S5810_194_0	1	5	Specialty Tier	1	4	010010	1	1	111100000001111000000101	31	60	90							1	31	60	90								10	31		31	14					394.98	33	33	33																					33	33	33																		33			33			33			
S5810	194	0		29	10	S5810_194_0	1	1	Preferred Generic	3	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00					1		
S5810	194	0		29	10	S5810_194_0	1	2	Non-Preferred Generic	3	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00					1		
S5810	194	0		29	10	S5810_194_0	1	3	Preferred Brand	3	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00		2		
S5810	194	0		29	10	S5810_194_0	1	4	Non-Preferred Brand	3	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					76.61	40	40	40																					40	40	40																		40						40	2		
S5810	194	0		29	10	S5810_194_0	1	1	Preferred Generic	1	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00							
S5810	195	0		29	10	S5810_195_0	1	3	Preferred Brand	3	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00		2		
S5810	195	0		29	10	S5810_195_0	1	2	Non-Preferred Generic	3	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00					1		
S5810	195	0		29	10	S5810_195_0	1	1	Preferred Generic	3	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00					1		
S5810	195	0		29	10	S5810_195_0	1	5	Specialty Tier	1	4	010010	1	1	111100000001111000000101	31	60	90							1	31	60	90								10	31		31	14					271.96	33	33	33																					33	33	33																		33			33			33			
S5810	195	0		29	10	S5810_195_0	1	4	Non-Preferred Brand	3	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					79.85	41	41	41																					41	41	41																		41						41	2		
S5810	195	0		29	10	S5810_195_0	1	3	Preferred Brand	1	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00				
S5810	195	0		29	10	S5810_195_0	1	2	Non-Preferred Generic	1	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00							
S5810	195	0		29	10	S5810_195_0	1	1	Preferred Generic	1	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00							
S5810	195	0		29	10	S5810_195_0	1	4	Non-Preferred Brand	1	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					79.85	41	41	41																					41	41	41																		41						41			
S5810	197	0		29	10	S5810_197_0	1	3	Preferred Brand	3	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00		2		
S5810	197	0		29	10	S5810_197_0	1	2	Non-Preferred Generic	3	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00					1		
S5810	197	0		29	10	S5810_197_0	1	1	Preferred Generic	3	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00					1		
S5810	197	0		29	10	S5810_197_0	1	5	Specialty Tier	1	4	010010	1	1	111100000001111000000101	31	60	90							1	31	60	90								10	31		31	14					200.83	33	33	33																					33	33	33																		33			33			33			
S5810	197	0		29	10	S5810_197_0	1	4	Non-Preferred Brand	1	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					93.43	44	44	44																					44	44	44																		44						44			
S5810	197	0		29	10	S5810_197_0	1	3	Preferred Brand	1	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00				
S5810	197	0		29	10	S5810_197_0	1	2	Non-Preferred Generic	1	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00							
S5810	197	0		29	10	S5810_197_0	1	1	Preferred Generic	1	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00							
S5810	197	0		29	10	S5810_197_0	1	4	Non-Preferred Brand	3	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					93.43	44	44	44																					44	44	44																		44						44	2		
S5810	198	0		29	10	S5810_198_0	1	3	Preferred Brand	3	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00		2		
S5810	198	0		29	10	S5810_198_0	1	2	Non-Preferred Generic	3	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00					1		
S5810	198	0		29	10	S5810_198_0	1	1	Preferred Generic	3	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00					1		
S5810	198	0		29	10	S5810_198_0	1	5	Specialty Tier	1	4	010010	1	1	111100000001111000000101	31	60	90							1	31	60	90								10	31		31	14					211.66	33	33	33																					33	33	33																		33			33			33			
S5810	198	0		29	10	S5810_198_0	1	4	Non-Preferred Brand	3	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					77.39	48	48	48																					48	48	48																		48						48	2		
S5810	198	0		29	10	S5810_198_0	1	3	Preferred Brand	1	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00				
S5810	198	0		29	10	S5810_198_0	1	2	Non-Preferred Generic	1	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00							
S5810	198	0		29	10	S5810_198_0	1	1	Preferred Generic	1	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00							
S5810	198	0		29	10	S5810_198_0	1	4	Non-Preferred Brand	1	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					77.39	48	48	48																					48	48	48																		48						48			
S5810	199	0		29	10	S5810_199_0	1	4	Non-Preferred Brand	3	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					93.50	48	48	48																					48	48	48																		48						48	2		
S5810	199	0		29	10	S5810_199_0	1	3	Preferred Brand	3	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00		2		
S5810	199	0		29	10	S5810_199_0	1	2	Non-Preferred Generic	3	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00					1		
S5810	199	0		29	10	S5810_199_0	1	1	Preferred Generic	3	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00					1		
S5810	199	0		29	10	S5810_199_0	1	5	Specialty Tier	1	4	010010	1	1	111100000001111000000101	31	60	90							1	31	60	90								10	31		31	14					531.51	33	33	33																					33	33	33																		33			33			33			
S5810	199	0		29	10	S5810_199_0	1	4	Non-Preferred Brand	1	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					93.50	48	48	48																					48	48	48																		48						48			
S5810	199	0		29	10	S5810_199_0	1	3	Preferred Brand	1	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00				
S5810	199	0		29	10	S5810_199_0	1	1	Preferred Generic	1	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00							
S5810	199	0		29	10	S5810_199_0	1	2	Non-Preferred Generic	1	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00							
S5810	200	0		29	10	S5810_200_0	1	4	Non-Preferred Brand	3	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					93.92	49	49	49																					49	49	49																		49						49	2		
S5810	200	0		29	10	S5810_200_0	1	3	Preferred Brand	3	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00		2		
S5810	200	0		29	10	S5810_200_0	1	1	Preferred Generic	1	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00							
S5810	200	0		29	10	S5810_200_0	1	2	Non-Preferred Generic	1	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00							
S5810	200	0		29	10	S5810_200_0	1	3	Preferred Brand	1	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00				
S5810	200	0		29	10	S5810_200_0	1	4	Non-Preferred Brand	1	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					93.92	49	49	49																					49	49	49																		49						49			
S5810	200	0		29	10	S5810_200_0	1	5	Specialty Tier	1	4	010010	1	1	111100000001111000000101	31	60	90							1	31	60	90								10	31		31	14					331.29	33	33	33																					33	33	33																		33			33			33			
S5810	200	0		29	10	S5810_200_0	1	1	Preferred Generic	3	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00					1		
S5810	200	0		29	10	S5810_200_0	1	2	Non-Preferred Generic	3	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00					1		
S5810	201	0		29	10	S5810_201_0	1	4	Non-Preferred Brand	3	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					94.37	47	47	47																					47	47	47																		47						47	2		
S5810	201	0		29	10	S5810_201_0	1	2	Non-Preferred Generic	1	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00							
S5810	201	0		29	10	S5810_201_0	1	3	Preferred Brand	1	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00				
S5810	201	0		29	10	S5810_201_0	1	4	Non-Preferred Brand	1	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					94.37	47	47	47																					47	47	47																		47						47			
S5810	201	0		29	10	S5810_201_0	1	1	Preferred Generic	1	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00							
S5810	201	0		29	10	S5810_201_0	1	1	Preferred Generic	3	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00					1		
S5810	201	0		29	10	S5810_201_0	1	2	Non-Preferred Generic	3	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00					1		
S5810	201	0		29	10	S5810_201_0	1	3	Preferred Brand	3	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00		2		
S5810	201	0		29	10	S5810_201_0	1	5	Specialty Tier	1	4	010010	1	1	111100000001111000000101	31	60	90							1	31	60	90								10	31		31	14					386.34	33	33	33																					33	33	33																		33			33			33			
S5810	202	0		29	10	S5810_202_0	1	3	Preferred Brand	3	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00		2		
S5810	202	0		29	10	S5810_202_0	1	4	Non-Preferred Brand	3	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					90.99	49	49	49																					49	49	49																		49						49	2		
S5810	202	0		29	10	S5810_202_0	1	2	Non-Preferred Generic	3	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00					1		
S5810	202	0		29	10	S5810_202_0	1	1	Preferred Generic	3	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00					1		
S5810	202	0		29	10	S5810_202_0	1	5	Specialty Tier	1	4	010010	1	1	111100000001111000000101	31	60	90							1	31	60	90								10	31		31	14					399.17	33	33	33																					33	33	33																		33			33			33			
S5810	202	0		29	10	S5810_202_0	1	4	Non-Preferred Brand	1	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					90.99	49	49	49																					49	49	49																		49						49			
S5810	202	0		29	10	S5810_202_0	1	3	Preferred Brand	1	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00				
S5810	202	0		29	10	S5810_202_0	1	2	Non-Preferred Generic	1	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00							
S5810	202	0		29	10	S5810_202_0	1	1	Preferred Generic	1	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00							
S5810	204	0		29	10	S5810_204_0	1	4	Non-Preferred Brand	3	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					93.81	50	50	50																					50	50	50																		50						50	2		
S5810	204	0		29	10	S5810_204_0	1	3	Preferred Brand	3	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00		2		
S5810	204	0		29	10	S5810_204_0	1	2	Non-Preferred Generic	3	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00					1		
S5810	204	0		29	10	S5810_204_0	1	1	Preferred Generic	3	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00					1		
S5810	204	0		29	10	S5810_204_0	1	1	Preferred Generic	1	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00							
S5810	204	0		29	10	S5810_204_0	1	4	Non-Preferred Brand	1	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					93.81	50	50	50																					50	50	50																		50						50			
S5810	204	0		29	10	S5810_204_0	1	3	Preferred Brand	1	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00				
S5810	204	0		29	10	S5810_204_0	1	2	Non-Preferred Generic	1	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00							
S5810	204	0		29	10	S5810_204_0	1	5	Specialty Tier	1	4	010010	1	1	111100000001111000000101	31	60	90							1	31	60	90								10	31		31	14					214.59	33	33	33																					33	33	33																		33			33			33			
S5810	239	0		29	10	S5810_239_0	1	2	Non-Preferred Generic	1	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00							
S5810	239	0		29	10	S5810_239_0	1	1	Preferred Generic	1	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00							
S5810	239	0		29	10	S5810_239_0	1	3	Preferred Brand	1	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00				
S5810	239	0		29	10	S5810_239_0	1	4	Non-Preferred Brand	1	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					94.24	38	38	38																					38	38	38																		38						38			
S5810	239	0		29	10	S5810_239_0	1	5	Specialty Tier	1	4	010010	1	1	111100000001111000000101	31	60	90							1	31	60	90								10	31		31	14					356.35	33	33	33																					33	33	33																		33			33			33			
S5810	239	0		29	10	S5810_239_0	1	1	Preferred Generic	3	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00					1		
S5810	239	0		29	10	S5810_239_0	1	2	Non-Preferred Generic	3	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00					1		
S5810	239	0		29	10	S5810_239_0	1	3	Preferred Brand	3	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00		2		
S5810	239	0		29	10	S5810_239_0	1	4	Non-Preferred Brand	3	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					94.24	38	38	38																					38	38	38																		38						38	2		
S5810	240	0		29	10	S5810_240_0	1	4	Non-Preferred Brand	3	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					92.59	37	37	37																					37	37	37																		37						37	2		
S5810	240	0		29	10	S5810_240_0	1	3	Preferred Brand	3	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00		2		
S5810	240	0		29	10	S5810_240_0	1	1	Preferred Generic	1	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00							
S5810	240	0		29	10	S5810_240_0	1	2	Non-Preferred Generic	1	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00							
S5810	240	0		29	10	S5810_240_0	1	3	Preferred Brand	1	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00				
S5810	240	0		29	10	S5810_240_0	1	4	Non-Preferred Brand	1	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					92.59	37	37	37																					37	37	37																		37						37			
S5810	240	0		29	10	S5810_240_0	1	5	Specialty Tier	1	4	010010	1	1	111100000001111000000101	31	60	90							1	31	60	90								10	31		31	14					423.36	33	33	33																					33	33	33																		33			33			33			
S5810	240	0		29	10	S5810_240_0	1	1	Preferred Generic	3	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00					1		
S5810	240	0		29	10	S5810_240_0	1	2	Non-Preferred Generic	3	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00					1		
S5810	241	0		29	10	S5810_241_0	1	4	Non-Preferred Brand	3	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					93.48	42	42	42																					42	42	42																		42						42	2		
S5810	241	0		29	10	S5810_241_0	1	2	Non-Preferred Generic	1	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00							
S5810	241	0		29	10	S5810_241_0	1	3	Preferred Brand	1	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00				
S5810	241	0		29	10	S5810_241_0	1	4	Non-Preferred Brand	1	4	100000	1	1	111100000001111000000001	31	60	90							1	31	60	90								10			31	14					93.48	42	42	42																					42	42	42																		42						42			
S5810	241	0		29	10	S5810_241_0	1	1	Preferred Generic	1	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00							
S5810	241	0		29	10	S5810_241_0	1	1	Preferred Generic	3	4	001000	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					5.00	10.00	15.00																						5.00	10.00	5.00																			5.00				5.00					1		
S5810	241	0		29	10	S5810_241_0	1	2	Non-Preferred Generic	3	4	000100	1	2	011100000001111000000100	31	60	90							1	31	60	90								10	31					33.00	66.00	99.00																						33.00	66.00	99.00																			33.00				33.00					1		
S5810	241	0		29	10	S5810_241_0	1	3	Preferred Brand	3	4	000001	1	2	111100000001111000000001	31	60	90							1	31	60	90								10			31	14		45.00	90.00	135.00																						45.00	90.00	135.00																			45.00							45.00		2		
S5810	241	0		29	10	S5810_241_0	1	5	Specialty Tier	1	4	010010	1	1	111100000001111000000101	31	60	90							1	31	60	90								10	31		31	14					320.89	33	33	33																					33	33	33																		33			33			33			
S5820	001	0		29	10	S5820_001_0	6	4	Non-Preferred Brand	1	3	100100		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										90.00		270.00						95.00		285.00															270.00							285.00				95.00					95.00			95.00				
S5820	001	0		29	10	S5820_001_0	6	3	Preferred Brand	1	3	010001		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															120.00							135.00				45.00					45.00			45.00				
S5820	001	0		29	10	S5820_001_0	6	2	Non-Preferred Generic	1	3	000100		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						10.00		30.00															15.00							30.00				10.00					10.00							
S5820	001	0		29	10	S5820_001_0	6	1	Preferred Generic	1	3	001000		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													3.00		9.00						8.00		24.00															9.00							24.00				8.00					8.00							
S5820	001	0		29	10	S5820_001_0	6	5	Specialty Tier	1	3	010010		1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													463.00	33		33					463.00	33		33														33							33			33				33			33			
S5820	002	0		29	10	S5820_002_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										85.00		255.00						95.00		285.00															240.00							285.00				95.00					95.00			95.00				
S5820	002	0		29	10	S5820_002_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5820	002	0		29	10	S5820_002_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						10.00		30.00															5.00							30.00				10.00					10.00							
S5820	002	0		29	10	S5820_002_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													3.00		9.00						6.00		18.00															0.00							18.00				6.00					6.00							
S5820	002	0		29	10	S5820_002_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													466.00	33		33					466.00	33		33														33							33			33				33			33			
S5820	003	0		29	10	S5820_003_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										85.00		255.00						95.00		285.00															240.00							285.00				95.00					95.00			95.00				
S5820	003	0		29	10	S5820_003_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5820	003	0		29	10	S5820_003_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						10.00		30.00															5.00							30.00				10.00					10.00							
S5820	003	0		29	10	S5820_003_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													3.00		9.00						6.00		18.00															0.00							18.00				6.00					6.00							
S5820	003	0		29	10	S5820_003_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													526.00	33		33					526.00	33		33														33							33			33				33			33			
S5820	004	0		29	10	S5820_004_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													3.00		9.00						6.00		18.00															0.00							18.00				6.00					6.00							
S5820	004	0		29	10	S5820_004_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						10.00		30.00															5.00							30.00				10.00					10.00							
S5820	004	0		29	10	S5820_004_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5820	004	0		29	10	S5820_004_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										85.00		255.00						95.00		285.00															240.00							285.00				95.00					95.00			95.00				
S5820	004	0		29	10	S5820_004_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													469.00	33		33					469.00	33		33														33							33			33				33			33			
S5820	005	0		29	10	S5820_005_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													475.00	33		33					475.00	33		33														33							33			33				33			33			
S5820	005	0		29	10	S5820_005_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										85.00		255.00						95.00		285.00															240.00							285.00				95.00					95.00			95.00				
S5820	005	0		29	10	S5820_005_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5820	005	0		29	10	S5820_005_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													3.00		9.00						6.00		18.00															0.00							18.00				6.00					6.00							
S5820	005	0		29	10	S5820_005_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						10.00		30.00															5.00							30.00				10.00					10.00							
S5820	006	0		29	10	S5820_006_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						10.00		30.00															5.00							30.00				10.00					10.00							
S5820	006	0		29	10	S5820_006_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5820	006	0		29	10	S5820_006_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										85.00		255.00						95.00		285.00															240.00							285.00				95.00					95.00			95.00				
S5820	006	0		29	10	S5820_006_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													3.00		9.00						6.00		18.00															0.00							18.00				6.00					6.00							
S5820	006	0		29	10	S5820_006_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													437.00	33		33					437.00	33		33														33							33			33				33			33			
S5820	007	0		29	10	S5820_007_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										85.00		255.00						95.00		285.00															240.00							285.00				95.00					95.00			95.00				
S5820	007	0		29	10	S5820_007_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						43.00		129.00															105.00							129.00				43.00					43.00			43.00				
S5820	007	0		29	10	S5820_007_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													3.00		9.00						6.00		18.00															0.00							18.00				6.00					6.00							
S5820	007	0		29	10	S5820_007_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						10.00		30.00															5.00							30.00				10.00					10.00							
S5820	007	0		29	10	S5820_007_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													479.00	33		33					479.00	33		33														33							33			33				33			33			
S5820	008	0		29	10	S5820_008_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													3.00		9.00						6.00		18.00															0.00							18.00				6.00					6.00							
S5820	008	0		29	10	S5820_008_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						10.00		30.00															5.00							30.00				10.00					10.00							
S5820	008	0		29	10	S5820_008_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5820	008	0		29	10	S5820_008_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										85.00		255.00						95.00		285.00															240.00							285.00				95.00					95.00			95.00				
S5820	008	0		29	10	S5820_008_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													544.00	33		33					544.00	33		33														33							33			33				33			33			
S5820	009	0		29	10	S5820_009_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										85.00		255.00						95.00		285.00															240.00							285.00				95.00					95.00			95.00				
S5820	009	0		29	10	S5820_009_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5820	009	0		29	10	S5820_009_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						10.00		30.00															5.00							30.00				10.00					10.00							
S5820	009	0		29	10	S5820_009_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													3.00		9.00						6.00		18.00															0.00							18.00				6.00					6.00							
S5820	009	0		29	10	S5820_009_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													502.00	33		33					502.00	33		33														33							33			33				33			33			
S5820	010	0		29	10	S5820_010_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													3.00		9.00						6.00		18.00															0.00							18.00				6.00					6.00							
S5820	010	0		29	10	S5820_010_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						10.00		30.00															5.00							30.00				10.00					10.00							
S5820	010	0		29	10	S5820_010_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5820	010	0		29	10	S5820_010_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										85.00		255.00						95.00		285.00															240.00							285.00				95.00					95.00			95.00				
S5820	010	0		29	10	S5820_010_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													499.00	33		33					499.00	33		33														33							33			33				33			33			
S5820	011	0		29	10	S5820_011_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													3.00		9.00						6.00		18.00															0.00							18.00				6.00					6.00							
S5820	011	0		29	10	S5820_011_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						9.00		27.00															5.00							27.00				9.00					9.00							
S5820	011	0		29	10	S5820_011_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5820	011	0		29	10	S5820_011_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										85.00		255.00						95.00		285.00															240.00							285.00				95.00					95.00			95.00				
S5820	011	0		29	10	S5820_011_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													503.00	33		33					503.00	33		33														33							33			33				33			33			
S5820	012	0		29	10	S5820_012_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													3.00		9.00						6.00		18.00															0.00							18.00				6.00					6.00							
S5820	012	0		29	10	S5820_012_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5820	012	0		29	10	S5820_012_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						10.00		30.00															5.00							30.00				10.00					10.00							
S5820	012	0		29	10	S5820_012_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										85.00		255.00						95.00		285.00															240.00							285.00				95.00					95.00			95.00				
S5820	012	0		29	10	S5820_012_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													507.00	33		33					507.00	33		33														33							33			33				33			33			
S5820	013	0		29	10	S5820_013_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						10.00		30.00															5.00							30.00				10.00					10.00							
S5820	013	0		29	10	S5820_013_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													3.00		9.00						6.00		18.00															0.00							18.00				6.00					6.00							
S5820	013	0		29	10	S5820_013_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5820	013	0		29	10	S5820_013_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										85.00		255.00						95.00		285.00															240.00							285.00				95.00					95.00			95.00				
S5820	013	0		29	10	S5820_013_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													475.00	33		33					475.00	33		33														33							33			33				33			33			
S5820	014	0		29	10	S5820_014_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													479.00	33		33					479.00	33		33														33							33			33				33			33			
S5820	014	0		29	10	S5820_014_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5820	014	0		29	10	S5820_014_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						10.00		30.00															5.00							30.00				10.00					10.00							
S5820	014	0		29	10	S5820_014_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										85.00		255.00						95.00		285.00															240.00							285.00				95.00					95.00			95.00				
S5820	014	0		29	10	S5820_014_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													3.00		9.00						6.00		18.00															0.00							18.00				6.00					6.00							
S5820	015	0		29	10	S5820_015_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													3.00		9.00						6.00		18.00															0.00							18.00				6.00					6.00							
S5820	015	0		29	10	S5820_015_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										85.00		255.00						95.00		285.00															240.00							285.00				95.00					95.00			95.00				
S5820	015	0		29	10	S5820_015_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													440.00	33		33					440.00	33		33														33							33			33				33			33			
S5820	015	0		29	10	S5820_015_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5820	015	0		29	10	S5820_015_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						10.00		30.00															5.00							30.00				10.00					10.00							
S5820	016	0		29	10	S5820_016_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													3.00		9.00						6.00		18.00															0.00							18.00				6.00					6.00							
S5820	016	0		29	10	S5820_016_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										85.00		255.00						95.00		285.00															240.00							285.00				95.00					95.00			95.00				
S5820	016	0		29	10	S5820_016_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						44.00		132.00															105.00							132.00				44.00					44.00			44.00				
S5820	016	0		29	10	S5820_016_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						10.00		30.00															5.00							30.00				10.00					10.00							
S5820	016	0		29	10	S5820_016_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													466.00	33		33					466.00	33		33														33							33			33				33			33			
S5820	017	0		29	10	S5820_017_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						10.00		30.00															5.00							30.00				10.00					10.00							
S5820	017	0		29	10	S5820_017_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													3.00		9.00						6.00		18.00															0.00							18.00				6.00					6.00							
S5820	017	0		29	10	S5820_017_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5820	017	0		29	10	S5820_017_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										85.00		255.00						95.00		285.00															240.00							285.00				95.00					95.00			95.00				
S5820	017	0		29	10	S5820_017_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													490.00	33		33					490.00	33		33														33							33			33				33			33			
S5820	018	0		29	10	S5820_018_0	7	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													577.00	33		33					577.00	33		33														33							33			33				33			33			
S5820	018	0		29	10	S5820_018_0	7	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						41.00		123.00															105.00							123.00				41.00					41.00			41.00				
S5820	018	0		29	10	S5820_018_0	7	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										85.00		255.00						95.00		285.00															240.00							285.00				95.00					95.00			95.00				
S5820	018	0		29	10	S5820_018_0	7	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						10.00		30.00															5.00							30.00				10.00					10.00							
S5820	018	0		29	10	S5820_018_0	7	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						5.00		15.00															0.00							15.00				5.00					5.00							
S5820	019	0		29	10	S5820_019_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													521.00	33		33					521.00	33		33														33							33			33				33			33			
S5820	019	0		29	10	S5820_019_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5820	019	0		29	10	S5820_019_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						9.00		27.00															5.00							27.00				9.00					9.00							
S5820	019	0		29	10	S5820_019_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5820	019	0		29	10	S5820_019_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										85.00		255.00						95.00		285.00															240.00							285.00				95.00					95.00			95.00				
S5820	020	0		29	10	S5820_020_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						43.00		129.00															105.00							129.00				43.00					43.00			43.00				
S5820	020	0		29	10	S5820_020_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										85.00		255.00						94.00		282.00															240.00							282.00				94.00					94.00			94.00				
S5820	020	0		29	10	S5820_020_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													494.00	33		33					494.00	33		33														33							33			33				33			33			
S5820	020	0		29	10	S5820_020_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5820	020	0		29	10	S5820_020_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						9.00		27.00															5.00							27.00				9.00					9.00							
S5820	021	0		29	10	S5820_021_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													512.00	33		33					512.00	33		33														33							33			33				33			33			
S5820	021	0		29	10	S5820_021_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										85.00		255.00						95.00		285.00															240.00							285.00				95.00					95.00			95.00				
S5820	021	0		29	10	S5820_021_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5820	021	0		29	10	S5820_021_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						10.00		30.00															5.00							30.00				10.00					10.00							
S5820	021	0		29	10	S5820_021_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													3.00		9.00						6.00		18.00															0.00							18.00				6.00					6.00							
S5820	022	0		29	10	S5820_022_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													481.00	33		33					481.00	33		33														33							33			33				33			33			
S5820	022	0		29	10	S5820_022_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										85.00		255.00						95.00		285.00															240.00							285.00				95.00					95.00			95.00				
S5820	022	0		29	10	S5820_022_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5820	022	0		29	10	S5820_022_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						10.00		30.00															5.00							30.00				10.00					10.00							
S5820	022	0		29	10	S5820_022_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													3.00		9.00						6.00		18.00															0.00							18.00				6.00					6.00							
S5820	023	0		29	10	S5820_023_0	7	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													3.00		9.00						6.00		18.00															0.00							18.00				6.00					6.00							
S5820	023	0		29	10	S5820_023_0	7	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						10.00		30.00															5.00							30.00				10.00					10.00							
S5820	023	0		29	10	S5820_023_0	7	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5820	023	0		29	10	S5820_023_0	7	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										85.00		255.00						95.00		285.00															240.00							285.00				95.00					95.00			95.00				
S5820	023	0		29	10	S5820_023_0	7	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													472.00	33		33					472.00	33		33														33							33			33				33			33			
S5820	024	0		29	10	S5820_024_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										85.00		255.00						95.00		285.00															240.00							285.00				95.00					95.00			95.00				
S5820	024	0		29	10	S5820_024_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5820	024	0		29	10	S5820_024_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						10.00		30.00															5.00							30.00				10.00					10.00							
S5820	024	0		29	10	S5820_024_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													3.00		9.00						6.00		18.00															0.00							18.00				6.00					6.00							
S5820	024	0		29	10	S5820_024_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													462.00	33		33					462.00	33		33														33							33			33				33			33			
S5820	025	0		29	10	S5820_025_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													3.00		9.00						6.00		18.00															0.00							18.00				6.00					6.00							
S5820	025	0		29	10	S5820_025_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										85.00		255.00						95.00		285.00															240.00							285.00				95.00					95.00			95.00				
S5820	025	0		29	10	S5820_025_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5820	025	0		29	10	S5820_025_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						10.00		30.00															5.00							30.00				10.00					10.00							
S5820	025	0		29	10	S5820_025_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													457.00	33		33					457.00	33		33														33							33			33				33			33			
S5820	026	0		29	10	S5820_026_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													432.00	33		33					432.00	33		33														33							33			33				33			33			
S5820	026	0		29	10	S5820_026_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										85.00		255.00						95.00		285.00															240.00							285.00				95.00					95.00			95.00				
S5820	026	0		29	10	S5820_026_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5820	026	0		29	10	S5820_026_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						10.00		30.00															5.00							30.00				10.00					10.00							
S5820	026	0		29	10	S5820_026_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													3.00		9.00						6.00		18.00															0.00							18.00				6.00					6.00							
S5820	027	0		29	10	S5820_027_0	6	5	Specialty Tier	1	3	010010		1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													444.00	33		33					444.00	33		33														33							33			33				33			33			
S5820	027	0		29	10	S5820_027_0	6	4	Non-Preferred Brand	1	3	100100		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										90.00		270.00						95.00		285.00															270.00							285.00				95.00					95.00			95.00				
S5820	027	0		29	10	S5820_027_0	6	3	Preferred Brand	1	3	010001		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															120.00							135.00				45.00					45.00			45.00				
S5820	027	0		29	10	S5820_027_0	6	2	Non-Preferred Generic	1	3	000100		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													8.00		24.00						11.00		33.00															24.00							33.00				11.00					11.00							
S5820	027	0		29	10	S5820_027_0	6	1	Preferred Generic	1	3	001000		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													4.00		12.00						7.00		21.00															12.00							21.00				7.00					7.00							
S5820	028	0		29	10	S5820_028_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													3.00		9.00						6.00		18.00															0.00							18.00				6.00					6.00							
S5820	028	0		29	10	S5820_028_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						10.00		30.00															5.00							30.00				10.00					10.00							
S5820	028	0		29	10	S5820_028_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5820	028	0		29	10	S5820_028_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										85.00		255.00						95.00		285.00															240.00							285.00				95.00					95.00			95.00				
S5820	028	0		29	10	S5820_028_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													536.00	33		33					536.00	33		33														33							33			33				33			33			
S5820	029	0		29	10	S5820_029_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						10.00		30.00															5.00							30.00				10.00					10.00							
S5820	029	0		29	10	S5820_029_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5820	029	0		29	10	S5820_029_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										85.00		255.00						95.00		285.00															240.00							285.00				95.00					95.00			95.00				
S5820	029	0		29	10	S5820_029_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													432.00	33		33					432.00	33		33														33							33			33				33			33			
S5820	029	0		29	10	S5820_029_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													3.00		9.00						6.00		18.00															0.00							18.00				6.00					6.00							
S5820	030	0		29	10	S5820_030_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													3.00		9.00						6.00		18.00															0.00							18.00				6.00					6.00							
S5820	030	0		29	10	S5820_030_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						10.00		30.00															5.00							30.00				10.00					10.00							
S5820	030	0		29	10	S5820_030_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5820	030	0		29	10	S5820_030_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													524.00	33		33					524.00	33		33														33							33			33				33			33			
S5820	030	0		29	10	S5820_030_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										85.00		255.00						95.00		285.00															240.00							285.00				95.00					95.00			95.00				
S5820	031	0		29	10	S5820_031_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													519.00	33		33					519.00	33		33														33							33			33				33			33			
S5820	031	0		29	10	S5820_031_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										85.00		255.00						95.00		285.00															240.00							285.00				95.00					95.00			95.00				
S5820	031	0		29	10	S5820_031_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5820	031	0		29	10	S5820_031_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						10.00		30.00															5.00							30.00				10.00					10.00							
S5820	031	0		29	10	S5820_031_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													3.00		9.00						6.00		18.00															0.00							18.00				6.00					6.00							
S5820	032	0		29	10	S5820_032_0	6	4	Non-Preferred Brand	1	3	100100		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										90.00		270.00						95.00		285.00															270.00							285.00				95.00					95.00			95.00				
S5820	032	0		29	10	S5820_032_0	6	5	Specialty Tier	1	3	010010		1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													489.00	33		33					489.00	33		33														33							33			33				33			33			
S5820	032	0		29	10	S5820_032_0	6	3	Preferred Brand	1	3	010001		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															120.00							135.00				45.00					45.00			45.00				
S5820	032	0		29	10	S5820_032_0	6	2	Non-Preferred Generic	1	3	000100		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													9.00		27.00						12.00		36.00															27.00							36.00				12.00					12.00							
S5820	032	0		29	10	S5820_032_0	6	1	Preferred Generic	1	3	001000		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													4.00		12.00						9.00		27.00															12.00							27.00				9.00					9.00							
S5820	033	0		29	10	S5820_033_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5820	033	0		29	10	S5820_033_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						10.00		30.00															5.00							30.00				10.00					10.00							
S5820	033	0		29	10	S5820_033_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										85.00		255.00						95.00		285.00															240.00							285.00				95.00					95.00			95.00				
S5820	033	0		29	10	S5820_033_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													404.00	33		33					404.00	33		33														33							33			33				33			33			
S5820	033	0		29	10	S5820_033_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													3.00		9.00						6.00		18.00															0.00							18.00				6.00					6.00							
S5820	034	0		29	10	S5820_034_0	6	5	Specialty Tier	1	3	010010		1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													643.00	33		33					643.00	33		33														33							33			33				33			33			
S5820	034	0		29	10	S5820_034_0	6	1	Preferred Generic	1	3	001000		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													3.00		9.00						8.00		24.00															9.00							24.00				8.00					8.00							
S5820	034	0		29	10	S5820_034_0	6	2	Non-Preferred Generic	1	3	000100		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						14.00		42.00															15.00							42.00				14.00					14.00							
S5820	034	0		29	10	S5820_034_0	6	3	Preferred Brand	1	3	010001		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															120.00							135.00				45.00					45.00			45.00				
S5820	034	0		29	10	S5820_034_0	6	4	Non-Preferred Brand	1	3	100100		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										85.00		255.00						95.00		285.00															255.00							285.00				95.00					95.00			95.00				
S5820	035	0		29	10	S5820_035_0	6	5	Specialty Tier	1	3	010010		1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													405.00	33		33					405.00	33		33														33							33			33				33			33			
S5820	035	0		29	10	S5820_035_0	6	2	Non-Preferred Generic	1	3	000100		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						13.00		39.00															15.00							39.00				13.00					13.00							
S5820	035	0		29	10	S5820_035_0	6	1	Preferred Generic	1	3	001000		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													3.00		9.00						6.00		18.00															9.00							18.00				6.00					6.00							
S5820	035	0		29	10	S5820_035_0	6	3	Preferred Brand	1	3	010001		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															120.00							135.00				45.00					45.00			45.00				
S5820	035	0		29	10	S5820_035_0	6	4	Non-Preferred Brand	1	3	100100		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										85.00		255.00						95.00		285.00															255.00							285.00				95.00					95.00			95.00				
S5820	036	0		29	10	S5820_036_0	6	4	Non-Preferred Brand	1	3	100100		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										85.00		255.00						95.00		285.00															255.00							285.00				95.00					95.00			95.00				
S5820	036	0		29	10	S5820_036_0	6	5	Specialty Tier	1	3	010010		1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													483.00	33		33					483.00	33		33														33							33			33				33			33			
S5820	036	0		29	10	S5820_036_0	6	1	Preferred Generic	1	3	001000		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													3.00		9.00						8.00		24.00															9.00							24.00				8.00					8.00							
S5820	036	0		29	10	S5820_036_0	6	2	Non-Preferred Generic	1	3	000100		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						13.00		39.00															15.00							39.00				13.00					13.00							
S5820	036	0		29	10	S5820_036_0	6	3	Preferred Brand	1	3	010001		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															120.00							135.00				45.00					45.00			45.00				
S5820	037	0		29	10	S5820_037_0	6	1	Preferred Generic	1	3	001000		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													3.00		9.00						7.00		21.00															9.00							21.00				7.00					7.00							
S5820	037	0		29	10	S5820_037_0	6	5	Specialty Tier	1	3	010010		1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													798.00	33		33					798.00	33		33														33							33			33				33			33			
S5820	037	0		29	10	S5820_037_0	6	3	Preferred Brand	1	3	010001		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															120.00							135.00				45.00					45.00			45.00				
S5820	037	0		29	10	S5820_037_0	6	4	Non-Preferred Brand	1	3	100100		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										85.00		255.00						95.00		285.00															255.00							285.00				95.00					95.00			95.00				
S5820	037	0		29	10	S5820_037_0	6	2	Non-Preferred Generic	1	3	000100		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						13.00		39.00															15.00							39.00				13.00					13.00							
S5820	038	0		29	10	S5820_038_0	6	5	Specialty Tier	1	3	010010		1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													528.00	33		33					528.00	33		33														33							33			33				33			33			
S5820	038	0		29	10	S5820_038_0	6	1	Preferred Generic	1	3	001000		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													4.00		12.00						10.00		30.00															12.00							30.00				10.00					10.00							
S5820	038	0		29	10	S5820_038_0	6	2	Non-Preferred Generic	1	3	000100		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													7.00		21.00						17.00		51.00															21.00							51.00				17.00					17.00							
S5820	038	0		29	10	S5820_038_0	6	3	Preferred Brand	1	3	010001		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															120.00							135.00				45.00					45.00			45.00				
S5820	038	0		29	10	S5820_038_0	6	4	Non-Preferred Brand	1	3	100100		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										85.00		255.00						95.00		285.00															255.00							285.00				95.00					95.00			95.00				
S5840	002	0		29	10	S5840_002_0	5	1	Preferred Generic	1	4	001000	1	2	010100000010000000000110	30		90							2										30		31	14				4.00		12.00																																										4.00					4.00							
S5840	002	0		29	10	S5840_002_0	5	2	Preferred Brand	1	4	000001	1	2	110100000010000000000001	30		90							2										30				31	14		20.00		60.00																																										20.00								20.00				
S5840	002	0		29	10	S5840_002_0	5	1	Preferred Generic	3	4	001000	1	2	010100000010000000000110	30		90							2										30		31	14				4.00		12.00																																										4.00					4.00					1		
S5840	002	0		29	10	S5840_002_0	5	4	Specialty Tier	1	4	000010	1	1	110100000010000000000001	30		90							2										30				31	14					288.00	25		25																																								25							25			
S5840	002	0		29	10	S5840_002_0	5	3	Non-Preferred Brand	1	4	100000	1	2	110100000010000000000001	30		90							2										30				31	14		45.00		135.00																																										45.00								45.00				
S5877	004	0		29	10	S5877_004_0	1	3	Non-Preferred Brand	1	2	100000		2	110100000001001000000001	34		90							2			90								29			34	14		90.00		270.00																								270.00																			90.00							90.00				
S5877	004	0		29	10	S5877_004_0	1	2	Preferred Brand	1	2	000001		2	110100000001001000000001	34		90							2			90								29			34	14		45.00		135.00																								135.00																			45.00							45.00				
S5877	004	0		29	10	S5877_004_0	1	1	Generic	1	2	010000		2	010100000001001000000100	34		90							2			90								29	34					6.00		18.00																								18.00																			6.00				6.00							
S5877	004	0		29	10	S5877_004_0	1	4	Specialty Tier	1	2	010010		2	110100000001001000000101	34		90							2			90								29	34		34	14		95.00		285.00																								285.00																			95.00				95.00			95.00				
S5877	007	0		29	10	S5877_007_0	2	3	Non-Preferred Brand	1	4	100000	1	1	110100000001001000000001	34		90							2			90								29			34	14					56.00	40		40																							40																		40						40			
S5877	007	0		29	10	S5877_007_0	2	2	Preferred Brand	1	4	000001	1	1	110100000001001000000001	34		90							2			90								29			34	14					32.00	20		20																							20																		20						20			
S5877	007	0		29	10	S5877_007_0	2	1	Generic	1	4	010000	1	1	010100000001001000000100	34		90							2			90								29	34								2.00	10		10																							10																		10			10						
S5877	007	0		29	10	S5877_007_0	2	4	Specialty Tier	1	4	010010	1	1	110100000001001000000101	34		90							2			90								29	34		34	14					1201.00	33		33																							33																		33			33			33			
S5884	001	0		29	10	S5884_001_0	2	4	Non-Preferred Brand	1	4	110000	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										90.00		270.00						90.00		270.00													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
S5884	001	0		29	10	S5884_001_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										2.00		6.00						5.00		15.00													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
S5884	001	0		29	10	S5884_001_0	2	2	Non-Preferred Generic	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						7.00		21.00													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
S5884	001	0		29	10	S5884_001_0	2	3	Preferred Brand	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										41.00		123.00						41.00		123.00													41.00		113.00					41.00		123.00				41.00					41.00			41.00				
S5884	001	0		29	10	S5884_001_0	2	5	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													778.00	33							761.00	33														33							33					33				33			33			
S5884	002	0		29	10	S5884_002_0	2	4	Non-Preferred Brand	1	4	110000	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										90.00		270.00						90.00		270.00													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
S5884	002	0		29	10	S5884_002_0	2	5	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													739.00	33							731.00	33														33							33					33				33			33			
S5884	002	0		29	10	S5884_002_0	2	3	Preferred Brand	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										44.00		132.00						44.00		132.00													44.00		122.00					44.00		132.00				44.00					44.00			44.00				
S5884	002	0		29	10	S5884_002_0	2	2	Non-Preferred Generic	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						7.00		21.00													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
S5884	002	0		29	10	S5884_002_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										2.00		6.00						5.00		15.00													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
S5884	004	0		29	10	S5884_004_0	2	5	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													605.00	33							597.00	33														33							33					33				33			33			
S5884	004	0		29	10	S5884_004_0	2	4	Non-Preferred Brand	1	4	110000	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										90.00		270.00						90.00		270.00													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
S5884	004	0		29	10	S5884_004_0	2	2	Non-Preferred Generic	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						7.00		21.00													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
S5884	004	0		29	10	S5884_004_0	2	3	Preferred Brand	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										43.00		129.00						43.00		129.00													43.00		119.00					43.00		129.00				43.00					43.00			43.00				
S5884	004	0		29	10	S5884_004_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										2.00		6.00						5.00		15.00													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
S5884	005	0		29	10	S5884_005_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										2.00		6.00						5.00		15.00													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
S5884	005	0		29	10	S5884_005_0	2	4	Non-Preferred Brand	1	4	110000	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										90.00		270.00						90.00		270.00													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
S5884	005	0		29	10	S5884_005_0	2	3	Preferred Brand	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										42.00		126.00						42.00		126.00													42.00		116.00					42.00		126.00				42.00					42.00			42.00				
S5884	005	0		29	10	S5884_005_0	2	2	Non-Preferred Generic	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						7.00		21.00													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
S5884	005	0		29	10	S5884_005_0	2	5	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													739.00	33							727.00	33														33							33					33				33			33			
S5884	008	0		29	10	S5884_008_0	2	5	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													796.00	33							787.00	33														33							33					33				33			33			
S5884	008	0		29	10	S5884_008_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										2.00		6.00						5.00		15.00													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
S5884	008	0		29	10	S5884_008_0	2	2	Non-Preferred Generic	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						7.00		21.00													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
S5884	008	0		29	10	S5884_008_0	2	3	Preferred Brand	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										41.00		123.00						41.00		123.00													41.00		113.00					41.00		123.00				41.00					41.00			41.00				
S5884	008	0		29	10	S5884_008_0	2	4	Non-Preferred Brand	1	4	110000	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										90.00		270.00						90.00		270.00													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
S5884	009	0		29	10	S5884_009_0	3	5	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													659.00	33							652.00	33														33							33					33				33			33			
S5884	009	0		29	10	S5884_009_0	3	4	Non-Preferred Brand	1	4	110000	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										90.00		270.00						90.00		270.00													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
S5884	009	0		29	10	S5884_009_0	3	3	Preferred Brand	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										42.00		126.00						42.00		126.00													42.00		116.00					42.00		126.00				42.00					42.00			42.00				
S5884	009	0		29	10	S5884_009_0	3	2	Non-Preferred Generic	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						7.00		21.00													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
S5884	009	0		29	10	S5884_009_0	3	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										2.00		6.00						5.00		15.00													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
S5884	010	0		29	10	S5884_010_0	2	5	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													677.00	33							668.00	33														33							33					33				33			33			
S5884	010	0		29	10	S5884_010_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										2.00		6.00						5.00		15.00													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
S5884	010	0		29	10	S5884_010_0	2	2	Non-Preferred Generic	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						7.00		21.00													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
S5884	010	0		29	10	S5884_010_0	2	3	Preferred Brand	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										41.00		123.00						41.00		123.00													41.00		113.00					41.00		123.00				41.00					41.00			41.00				
S5884	010	0		29	10	S5884_010_0	2	4	Non-Preferred Brand	1	4	110000	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										90.00		270.00						90.00		270.00													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
S5884	015	0		29	10	S5884_015_0	1	4	Non-Preferred Brand	1	4	110000	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										90.00		270.00						90.00		270.00													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
S5884	015	0		29	10	S5884_015_0	1	5	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													873.00	33							859.00	33														33							33					33				33			33			
S5884	015	0		29	10	S5884_015_0	1	3	Preferred Brand	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										41.00		123.00						41.00		123.00													41.00		113.00					41.00		123.00				41.00					41.00			41.00				
S5884	015	0		29	10	S5884_015_0	1	2	Non-Preferred Generic	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						7.00		21.00													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
S5884	015	0		29	10	S5884_015_0	1	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										2.00		6.00						5.00		15.00													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
S5884	019	0		29	10	S5884_019_0	1	4	Non-Preferred Brand	1	4	110000	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										90.00		270.00						90.00		270.00													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
S5884	019	0		29	10	S5884_019_0	1	3	Preferred Brand	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										41.00		123.00						41.00		123.00													41.00		113.00					41.00		123.00				41.00					41.00			41.00				
S5884	019	0		29	10	S5884_019_0	1	2	Non-Preferred Generic	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						7.00		21.00													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
S5884	019	0		29	10	S5884_019_0	1	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										2.00		6.00						5.00		15.00													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
S5884	019	0		29	10	S5884_019_0	1	5	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													658.00	33							644.00	33														33							33					33				33			33			
S5884	020	0		29	10	S5884_020_0	1	3	Preferred Brand	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										41.00		123.00						41.00		123.00													41.00		113.00					41.00		123.00				41.00					41.00			41.00				
S5884	020	0		29	10	S5884_020_0	1	2	Non-Preferred Generic	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						7.00		21.00													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
S5884	020	0		29	10	S5884_020_0	1	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										2.00		6.00						5.00		15.00													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
S5884	020	0		29	10	S5884_020_0	1	5	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													738.00	33							730.00	33														33							33					33				33			33			
S5884	020	0		29	10	S5884_020_0	1	4	Non-Preferred Brand	1	4	110000	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										90.00		270.00						90.00		270.00													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
S5884	021	0		29	10	S5884_021_0	1	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										2.00		6.00						5.00		15.00													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
S5884	021	0		29	10	S5884_021_0	1	2	Non-Preferred Generic	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						7.00		21.00													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
S5884	021	0		29	10	S5884_021_0	1	4	Non-Preferred Brand	1	4	110000	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										90.00		270.00						90.00		270.00													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
S5884	021	0		29	10	S5884_021_0	1	3	Preferred Brand	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										41.00		123.00						41.00		123.00													41.00		113.00					41.00		123.00				41.00					41.00			41.00				
S5884	021	0		29	10	S5884_021_0	1	5	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													782.00	33							759.00	33														33							33					33				33			33			
S5884	022	0		29	10	S5884_022_0	1	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										2.00		6.00						5.00		15.00													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
S5884	022	0		29	10	S5884_022_0	1	2	Non-Preferred Generic	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						7.00		21.00													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
S5884	022	0		29	10	S5884_022_0	1	3	Preferred Brand	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										38.00		114.00						38.00		114.00													38.00		104.00					38.00		114.00				38.00					38.00			38.00				
S5884	022	0		29	10	S5884_022_0	1	4	Non-Preferred Brand	1	4	110000	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										90.00		270.00						90.00		270.00													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
S5884	022	0		29	10	S5884_022_0	1	5	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													740.00	33							725.00	33														33							33					33				33			33			
S5884	024	0		29	10	S5884_024_0	1	5	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													666.00	33							650.00	33														33							33					33				33			33			
S5884	024	0		29	10	S5884_024_0	1	4	Non-Preferred Brand	1	4	110000	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										90.00		270.00						90.00		270.00													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
S5884	024	0		29	10	S5884_024_0	1	2	Non-Preferred Generic	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						7.00		21.00													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
S5884	024	0		29	10	S5884_024_0	1	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										2.00		6.00						5.00		15.00													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
S5884	024	0		29	10	S5884_024_0	1	3	Preferred Brand	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										42.00		126.00						42.00		126.00													42.00		116.00					42.00		126.00				42.00					42.00			42.00				
S5884	028	0		29	10	S5884_028_0	1	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										2.00		6.00						5.00		15.00													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
S5884	028	0		29	10	S5884_028_0	1	2	Non-Preferred Generic	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						7.00		21.00													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
S5884	028	0		29	10	S5884_028_0	1	3	Preferred Brand	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										42.00		126.00						42.00		126.00													42.00		116.00					42.00		126.00				42.00					42.00			42.00				
S5884	028	0		29	10	S5884_028_0	1	4	Non-Preferred Brand	1	4	110000	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										90.00		270.00						90.00		270.00													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
S5884	028	0		29	10	S5884_028_0	1	5	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													760.00	33							750.00	33														33							33					33				33			33			
S5884	030	0		29	10	S5884_030_0	1	4	Non-Preferred Brand	1	4	110000	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										90.00		270.00						90.00		270.00													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
S5884	030	0		29	10	S5884_030_0	1	3	Preferred Brand	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										44.00		132.00						44.00		132.00													44.00		122.00					44.00		132.00				44.00					44.00			44.00				
S5884	030	0		29	10	S5884_030_0	1	2	Non-Preferred Generic	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						7.00		21.00													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
S5884	030	0		29	10	S5884_030_0	1	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										2.00		6.00						5.00		15.00													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
S5884	030	0		29	10	S5884_030_0	1	5	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													654.00	33							650.00	33														33							33					33				33			33			
S5884	031	0		29	10	S5884_031_0	2	3	Non-Preferred Brand	3	4	100100	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													137.00	50		50					151.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	031	0		29	10	S5884_031_0	2	1	Preferred Generic	3	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						10.00		30.00													0.00		0.00					5.00		15.00				10.00					5.00			5.00		1		
S5884	031	0		29	10	S5884_031_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													714.00	33							714.00	33														33							33					33				33			33			
S5884	031	0		29	10	S5884_031_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										72.00		216.00						77.00		231.00													72.00		206.00					72.00		216.00				77.00					72.00			72.00				
S5884	031	0		29	10	S5884_031_0	2	2	Preferred Brand	1	4	010001	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										38.00		114.00						43.00		129.00													38.00		104.00					38.00		114.00				43.00					38.00			38.00				
S5884	031	0		29	10	S5884_031_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						10.00		30.00													0.00		0.00					5.00		15.00				10.00					5.00			5.00				
S5884	031	0		29	10	S5884_031_0	2	2	Preferred Brand	3	4	010001	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													73.00	50		50					80.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	032	0		29	10	S5884_032_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													795.00	33							795.00	33														33							33					33				33			33			
S5884	032	0		29	10	S5884_032_0	2	1	Preferred Generic	3	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						10.00		30.00													0.00		0.00					5.00		15.00				10.00					5.00			5.00		1		
S5884	032	0		29	10	S5884_032_0	2	2	Preferred Brand	3	4	010001	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													73.00	50		50					80.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	032	0		29	10	S5884_032_0	2	3	Non-Preferred Brand	3	4	100100	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													118.00	50		50					130.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	032	0		29	10	S5884_032_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						10.00		30.00													0.00		0.00					5.00		15.00				10.00					5.00			5.00				
S5884	032	0		29	10	S5884_032_0	2	2	Preferred Brand	1	4	010001	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										38.00		114.00						43.00		129.00													38.00		104.00					38.00		114.00				43.00					38.00			38.00				
S5884	032	0		29	10	S5884_032_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										71.00		213.00						76.00		228.00													71.00		203.00					71.00		213.00				76.00					71.00			71.00				
S5884	033	0		29	10	S5884_033_0	2	3	Non-Preferred Brand	3	4	100100	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													120.00	50		50					132.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	033	0		29	10	S5884_033_0	2	2	Preferred Brand	3	4	010001	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													70.00	50		50					76.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	033	0		29	10	S5884_033_0	2	1	Preferred Generic	3	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						10.00		30.00													0.00		0.00					5.00		15.00				10.00					5.00			5.00		1		
S5884	033	0		29	10	S5884_033_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													605.00	33							605.00	33														33							33					33				33			33			
S5884	033	0		29	10	S5884_033_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										75.00		225.00						80.00		240.00													75.00		215.00					75.00		225.00				80.00					75.00			75.00				
S5884	033	0		29	10	S5884_033_0	2	2	Preferred Brand	1	4	010001	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										38.00		114.00						43.00		129.00													38.00		104.00					38.00		114.00				43.00					38.00			38.00				
S5884	033	0		29	10	S5884_033_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						10.00		30.00													0.00		0.00					5.00		15.00				10.00					5.00			5.00				
S5884	034	0		29	10	S5884_034_0	2	2	Preferred Brand	3	4	010001	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													70.00	50		50					77.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	034	0		29	10	S5884_034_0	2	3	Non-Preferred Brand	3	4	100100	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													123.00	50		50					135.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	034	0		29	10	S5884_034_0	2	1	Preferred Generic	3	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						10.00		30.00													0.00		0.00					5.00		15.00				10.00					5.00			5.00		1		
S5884	034	0		29	10	S5884_034_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													826.00	33							826.00	33														33							33					33				33			33			
S5884	034	0		29	10	S5884_034_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										72.00		216.00						77.00		231.00													72.00		206.00					72.00		216.00				77.00					72.00			72.00				
S5884	034	0		29	10	S5884_034_0	2	2	Preferred Brand	1	4	010001	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										37.00		111.00						42.00		126.00													37.00		101.00					37.00		111.00				42.00					37.00			37.00				
S5884	034	0		29	10	S5884_034_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						10.00		30.00													0.00		0.00					5.00		15.00				10.00					5.00			5.00				
S5884	035	0		29	10	S5884_035_0	2	3	Non-Preferred Brand	3	4	100100	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													130.00	50		50					143.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	035	0		29	10	S5884_035_0	2	2	Preferred Brand	3	4	010001	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													69.00	50		50					76.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	035	0		29	10	S5884_035_0	2	1	Preferred Generic	3	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						10.00		30.00													0.00		0.00					5.00		15.00				10.00					5.00			5.00		1		
S5884	035	0		29	10	S5884_035_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													590.00	33							590.00	33														33							33					33				33			33			
S5884	035	0		29	10	S5884_035_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										72.00		216.00						77.00		231.00													72.00		206.00					72.00		216.00				77.00					72.00			72.00				
S5884	035	0		29	10	S5884_035_0	2	2	Preferred Brand	1	4	010001	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										37.00		111.00						42.00		126.00													37.00		101.00					37.00		111.00				42.00					37.00			37.00				
S5884	035	0		29	10	S5884_035_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						10.00		30.00													0.00		0.00					5.00		15.00				10.00					5.00			5.00				
S5884	036	0		29	10	S5884_036_0	2	2	Preferred Brand	3	4	010001	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													70.00	50		50					77.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	036	0		29	10	S5884_036_0	2	1	Preferred Generic	3	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						10.00		30.00													0.00		0.00					5.00		15.00				10.00					5.00			5.00		1		
S5884	036	0		29	10	S5884_036_0	2	3	Non-Preferred Brand	3	4	100100	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													117.00	50		50					129.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	036	0		29	10	S5884_036_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													641.00	33							641.00	33														33							33					33				33			33			
S5884	036	0		29	10	S5884_036_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										72.00		216.00						77.00		231.00													72.00		206.00					72.00		216.00				77.00					72.00			72.00				
S5884	036	0		29	10	S5884_036_0	2	2	Preferred Brand	1	4	010001	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										37.00		111.00						42.00		126.00													37.00		101.00					37.00		111.00				42.00					37.00			37.00				
S5884	036	0		29	10	S5884_036_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						10.00		30.00													0.00		0.00					5.00		15.00				10.00					5.00			5.00				
S5884	037	0		29	10	S5884_037_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													1114.00	33							1114.00	33														33							33					33				33			33			
S5884	037	0		29	10	S5884_037_0	2	2	Preferred Brand	1	4	010001	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										37.00		111.00						42.00		126.00													37.00		101.00					37.00		111.00				42.00					37.00			37.00				
S5884	037	0		29	10	S5884_037_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										69.00		207.00						74.00		222.00													69.00		197.00					69.00		207.00				74.00					69.00			69.00				
S5884	037	0		29	10	S5884_037_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						10.00		30.00													0.00		0.00					5.00		15.00				10.00					5.00			5.00				
S5884	037	0		29	10	S5884_037_0	2	3	Non-Preferred Brand	3	4	100100	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													124.00	50		50					136.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	037	0		29	10	S5884_037_0	2	2	Preferred Brand	3	4	010001	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													66.00	50		50					73.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	037	0		29	10	S5884_037_0	2	1	Preferred Generic	3	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						10.00		30.00													0.00		0.00					5.00		15.00				10.00					5.00			5.00		1		
S5884	038	0		29	10	S5884_038_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													695.00	33							695.00	33														33							33					33				33			33			
S5884	038	0		29	10	S5884_038_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										69.00		207.00						74.00		222.00													69.00		197.00					69.00		207.00				74.00					69.00			69.00				
S5884	038	0		29	10	S5884_038_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										4.00		12.00						9.00		27.00													0.00		0.00					4.00		12.00				9.00					4.00			4.00				
S5884	038	0		29	10	S5884_038_0	2	2	Preferred Brand	1	4	010001	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										37.00		111.00						42.00		126.00													37.00		101.00					37.00		111.00				42.00					37.00			37.00				
S5884	038	0		29	10	S5884_038_0	2	1	Preferred Generic	3	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										4.00		12.00						9.00		27.00													0.00		0.00					4.00		12.00				9.00					4.00			4.00		1		
S5884	038	0		29	10	S5884_038_0	2	2	Preferred Brand	3	4	010001	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													66.00	50		50					73.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	038	0		29	10	S5884_038_0	2	3	Non-Preferred Brand	3	4	100100	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													119.00	50		50					131.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	039	0		29	10	S5884_039_0	2	2	Preferred Brand	1	4	010001	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										37.00		111.00						42.00		126.00													37.00		101.00					37.00		111.00				42.00					37.00			37.00				
S5884	039	0		29	10	S5884_039_0	2	3	Non-Preferred Brand	3	4	100100	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													116.00	50		50					128.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	039	0		29	10	S5884_039_0	2	2	Preferred Brand	3	4	010001	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													68.00	50		50					75.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	039	0		29	10	S5884_039_0	2	1	Preferred Generic	3	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										4.00		12.00						9.00		27.00													0.00		0.00					4.00		12.00				9.00					4.00			4.00		1		
S5884	039	0		29	10	S5884_039_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													730.00	33							730.00	33														33							33					33				33			33			
S5884	039	0		29	10	S5884_039_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										68.00		204.00						73.00		219.00													68.00		194.00					68.00		204.00				73.00					68.00			68.00				
S5884	039	0		29	10	S5884_039_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										4.00		12.00						9.00		27.00													0.00		0.00					4.00		12.00				9.00					4.00			4.00				
S5884	040	0		29	10	S5884_040_0	2	3	Non-Preferred Brand	3	4	100100	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													110.00	50		50					121.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	040	0		29	10	S5884_040_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													740.00	33							740.00	33														33							33					33				33			33			
S5884	040	0		29	10	S5884_040_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										70.00		210.00						75.00		225.00													70.00		200.00					70.00		210.00				75.00					70.00			70.00				
S5884	040	0		29	10	S5884_040_0	2	2	Preferred Brand	1	4	010001	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										36.00		108.00						41.00		123.00													36.00		98.00					36.00		108.00				41.00					36.00			36.00				
S5884	040	0		29	10	S5884_040_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										4.00		12.00						9.00		27.00													0.00		0.00					4.00		12.00				9.00					4.00			4.00				
S5884	040	0		29	10	S5884_040_0	2	1	Preferred Generic	3	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										4.00		12.00						9.00		27.00													0.00		0.00					4.00		12.00				9.00					4.00			4.00		1		
S5884	040	0		29	10	S5884_040_0	2	2	Preferred Brand	3	4	010001	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													67.00	50		50					73.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	041	0		29	10	S5884_041_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						10.00		30.00													0.00		0.00					5.00		15.00				10.00					5.00			5.00				
S5884	041	0		29	10	S5884_041_0	2	1	Preferred Generic	3	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						10.00		30.00													0.00		0.00					5.00		15.00				10.00					5.00			5.00		1		
S5884	041	0		29	10	S5884_041_0	2	2	Preferred Brand	1	4	010001	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										39.00		117.00						44.00		132.00													39.00		107.00					39.00		117.00				44.00					39.00			39.00				
S5884	041	0		29	10	S5884_041_0	2	3	Non-Preferred Brand	3	4	100100	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													134.00	50		50					148.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	041	0		29	10	S5884_041_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										70.00		210.00						75.00		225.00													70.00		200.00					70.00		210.00				75.00					70.00			70.00				
S5884	041	0		29	10	S5884_041_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													738.00	33							738.00	33														33							33					33				33			33			
S5884	041	0		29	10	S5884_041_0	2	2	Preferred Brand	3	4	010001	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													70.00	50		50					77.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	042	0		29	10	S5884_042_0	2	3	Non-Preferred Brand	3	4	100100	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													129.00	50		50					141.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	042	0		29	10	S5884_042_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						10.00		30.00													0.00		0.00					5.00		15.00				10.00					5.00			5.00				
S5884	042	0		29	10	S5884_042_0	2	2	Preferred Brand	1	4	010001	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										38.00		114.00						43.00		129.00													38.00		104.00					38.00		114.00				43.00					38.00			38.00				
S5884	042	0		29	10	S5884_042_0	2	2	Preferred Brand	3	4	010001	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													69.00	50		50					76.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	042	0		29	10	S5884_042_0	2	1	Preferred Generic	3	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						10.00		30.00													0.00		0.00					5.00		15.00				10.00					5.00			5.00		1		
S5884	042	0		29	10	S5884_042_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													750.00	33							750.00	33														33							33					33				33			33			
S5884	042	0		29	10	S5884_042_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										71.00		213.00						76.00		228.00													71.00		203.00					71.00		213.00				76.00					71.00			71.00				
S5884	043	0		29	10	S5884_043_0	2	2	Preferred Brand	3	4	010001	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													68.00	50		50					75.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	043	0		29	10	S5884_043_0	2	3	Non-Preferred Brand	3	4	100100	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													123.00	50		50					135.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	043	0		29	10	S5884_043_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										4.00		12.00						9.00		27.00													0.00		0.00					4.00		12.00				9.00					4.00			4.00				
S5884	043	0		29	10	S5884_043_0	2	2	Preferred Brand	1	4	010001	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										37.00		111.00						42.00		126.00													37.00		101.00					37.00		111.00				42.00					37.00			37.00				
S5884	043	0		29	10	S5884_043_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										70.00		210.00						75.00		225.00													70.00		200.00					70.00		210.00				75.00					70.00			70.00				
S5884	043	0		29	10	S5884_043_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													822.00	33							822.00	33														33							33					33				33			33			
S5884	043	0		29	10	S5884_043_0	2	1	Preferred Generic	3	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										4.00		12.00						9.00		27.00													0.00		0.00					4.00		12.00				9.00					4.00			4.00		1		
S5884	044	0		29	10	S5884_044_0	2	2	Preferred Brand	3	4	010001	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													70.00	50		50					77.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	044	0		29	10	S5884_044_0	2	3	Non-Preferred Brand	3	4	100100	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													120.00	50		50					132.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	044	0		29	10	S5884_044_0	2	2	Preferred Brand	1	4	010001	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										40.00		120.00						45.00		135.00													40.00		110.00					40.00		120.00				45.00					40.00			40.00				
S5884	044	0		29	10	S5884_044_0	2	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										73.00		219.00						78.00		234.00													73.00		209.00					73.00		219.00				78.00					73.00			73.00				
S5884	044	0		29	10	S5884_044_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						10.00		30.00													0.00		0.00					5.00		15.00				10.00					5.00			5.00				
S5884	044	0		29	10	S5884_044_0	2	1	Preferred Generic	3	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						10.00		30.00													0.00		0.00					5.00		15.00				10.00					5.00			5.00		1		
S5884	044	0		29	10	S5884_044_0	2	4	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													458.00	33							458.00	33														33							33					33				33			33			
S5884	045	0		29	10	S5884_045_0	1	2	Preferred Brand	1	4	010001	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										36.00		108.00						41.00		123.00													36.00		98.00					36.00		108.00				41.00					36.00			36.00				
S5884	045	0		29	10	S5884_045_0	1	3	Non-Preferred Brand	3	4	100100	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													124.00	50		50					137.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	045	0		29	10	S5884_045_0	1	2	Preferred Brand	3	4	010001	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													70.00	50		50					77.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	045	0		29	10	S5884_045_0	1	1	Preferred Generic	3	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						10.00		30.00													0.00		0.00					5.00		15.00				10.00					5.00			5.00		1		
S5884	045	0		29	10	S5884_045_0	1	4	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													875.00	33							875.00	33														33							33					33				33			33			
S5884	045	0		29	10	S5884_045_0	1	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										68.00		204.00						73.00		219.00													68.00		194.00					68.00		204.00				73.00					68.00			68.00				
S5884	045	0		29	10	S5884_045_0	1	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						10.00		30.00													0.00		0.00					5.00		15.00				10.00					5.00			5.00				
S5884	046	0		29	10	S5884_046_0	1	3	Non-Preferred Brand	3	4	100100	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													124.00	50		50					137.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	046	0		29	10	S5884_046_0	1	2	Preferred Brand	3	4	010001	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													67.00	50		50					74.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	046	0		29	10	S5884_046_0	1	1	Preferred Generic	3	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						10.00		30.00													0.00		0.00					5.00		15.00				10.00					5.00			5.00		1		
S5884	046	0		29	10	S5884_046_0	1	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										71.00		213.00						76.00		228.00													71.00		203.00					71.00		213.00				76.00					71.00			71.00				
S5884	046	0		29	10	S5884_046_0	1	4	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													735.00	33							735.00	33														33							33					33				33			33			
S5884	046	0		29	10	S5884_046_0	1	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						10.00		30.00													0.00		0.00					5.00		15.00				10.00					5.00			5.00				
S5884	046	0		29	10	S5884_046_0	1	2	Preferred Brand	1	4	010001	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										39.00		117.00						44.00		132.00													39.00		107.00					39.00		117.00				44.00					39.00			39.00				
S5884	047	0		29	10	S5884_047_0	1	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						10.00		30.00													0.00		0.00					5.00		15.00				10.00					5.00			5.00				
S5884	047	0		29	10	S5884_047_0	1	3	Non-Preferred Brand	3	4	100100	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													112.00	50		50					124.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	047	0		29	10	S5884_047_0	1	1	Preferred Generic	3	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						10.00		30.00													0.00		0.00					5.00		15.00				10.00					5.00			5.00		1		
S5884	047	0		29	10	S5884_047_0	1	2	Preferred Brand	3	4	010001	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													62.00	50		50					68.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	047	0		29	10	S5884_047_0	1	4	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													856.00	33							856.00	33														33							33					33				33			33			
S5884	047	0		29	10	S5884_047_0	1	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										71.00		213.00						76.00		228.00													71.00		203.00					71.00		213.00				76.00					71.00			71.00				
S5884	047	0		29	10	S5884_047_0	1	2	Preferred Brand	1	4	010001	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										36.00		108.00						41.00		123.00													36.00		98.00					36.00		108.00				41.00					36.00			36.00				
S5884	048	0		29	10	S5884_048_0	1	3	Non-Preferred Brand	3	4	100100	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													105.00	50		50					116.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	048	0		29	10	S5884_048_0	1	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						10.00		30.00													0.00		0.00					5.00		15.00				10.00					5.00			5.00				
S5884	048	0		29	10	S5884_048_0	1	2	Preferred Brand	1	4	010001	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										37.00		111.00						42.00		126.00													37.00		101.00					37.00		111.00				42.00					37.00			37.00				
S5884	048	0		29	10	S5884_048_0	1	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										69.00		207.00						74.00		222.00													69.00		197.00					69.00		207.00				74.00					69.00			69.00				
S5884	048	0		29	10	S5884_048_0	1	4	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													902.00	33							902.00	33														33							33					33				33			33			
S5884	048	0		29	10	S5884_048_0	1	1	Preferred Generic	3	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						10.00		30.00													0.00		0.00					5.00		15.00				10.00					5.00			5.00		1		
S5884	048	0		29	10	S5884_048_0	1	2	Preferred Brand	3	4	010001	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													67.00	50		50					74.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	049	0		29	10	S5884_049_0	1	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										4.00		12.00						9.00		27.00													0.00		0.00					4.00		12.00				9.00					4.00			4.00				
S5884	049	0		29	10	S5884_049_0	1	2	Preferred Brand	1	4	010001	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										37.00		111.00						42.00		126.00													37.00		101.00					37.00		111.00				42.00					37.00			37.00				
S5884	049	0		29	10	S5884_049_0	1	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										70.00		210.00						75.00		225.00													70.00		200.00					70.00		210.00				75.00					70.00			70.00				
S5884	049	0		29	10	S5884_049_0	1	3	Non-Preferred Brand	3	4	100100	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													111.00	50		50					122.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	049	0		29	10	S5884_049_0	1	1	Preferred Generic	3	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										4.00		12.00						9.00		27.00													0.00		0.00					4.00		12.00				9.00					4.00			4.00		1		
S5884	049	0		29	10	S5884_049_0	1	2	Preferred Brand	3	4	010001	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													66.00	50		50					73.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	049	0		29	10	S5884_049_0	1	4	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													667.00	33							667.00	33														33							33					33				33			33			
S5884	050	0		29	10	S5884_050_0	1	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										68.00		204.00						73.00		219.00													68.00		194.00					68.00		204.00				73.00					68.00			68.00				
S5884	050	0		29	10	S5884_050_0	1	4	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													740.00	33							740.00	33														33							33					33				33			33			
S5884	050	0		29	10	S5884_050_0	1	1	Preferred Generic	3	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						10.00		30.00													0.00		0.00					5.00		15.00				10.00					5.00			5.00		1		
S5884	050	0		29	10	S5884_050_0	1	2	Preferred Brand	3	4	010001	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													69.00	50		50					76.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	050	0		29	10	S5884_050_0	1	3	Non-Preferred Brand	3	4	100100	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													113.00	50		50					124.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	050	0		29	10	S5884_050_0	1	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						10.00		30.00													0.00		0.00					5.00		15.00				10.00					5.00			5.00				
S5884	050	0		29	10	S5884_050_0	1	2	Preferred Brand	1	4	010001	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										38.00		114.00						43.00		129.00													38.00		104.00					38.00		114.00				43.00					38.00			38.00				
S5884	051	0		29	10	S5884_051_0	1	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						10.00		30.00													0.00		0.00					5.00		15.00				10.00					5.00			5.00				
S5884	051	0		29	10	S5884_051_0	1	2	Preferred Brand	1	4	010001	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										36.00		108.00						41.00		123.00													36.00		98.00					36.00		108.00				41.00					36.00			36.00				
S5884	051	0		29	10	S5884_051_0	1	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										69.00		207.00						74.00		222.00													69.00		197.00					69.00		207.00				74.00					69.00			69.00				
S5884	051	0		29	10	S5884_051_0	1	4	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													754.00	33							754.00	33														33							33					33				33			33			
S5884	051	0		29	10	S5884_051_0	1	1	Preferred Generic	3	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						10.00		30.00													0.00		0.00					5.00		15.00				10.00					5.00			5.00		1		
S5884	051	0		29	10	S5884_051_0	1	2	Preferred Brand	3	4	010001	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													69.00	50		50					76.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	051	0		29	10	S5884_051_0	1	3	Non-Preferred Brand	3	4	100100	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													119.00	50		50					131.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	052	0		29	10	S5884_052_0	1	1	Preferred Generic	3	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										4.00		12.00						9.00		27.00													0.00		0.00					4.00		12.00				9.00					4.00			4.00		1		
S5884	052	0		29	10	S5884_052_0	1	4	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													779.00	33							779.00	33														33							33					33				33			33			
S5884	052	0		29	10	S5884_052_0	1	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										74.00		222.00						79.00		237.00													74.00		212.00					74.00		222.00				79.00					74.00			74.00				
S5884	052	0		29	10	S5884_052_0	1	2	Preferred Brand	1	4	010001	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										37.00		111.00						42.00		126.00													37.00		101.00					37.00		111.00				42.00					37.00			37.00				
S5884	052	0		29	10	S5884_052_0	1	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										4.00		12.00						9.00		27.00													0.00		0.00					4.00		12.00				9.00					4.00			4.00				
S5884	052	0		29	10	S5884_052_0	1	3	Non-Preferred Brand	3	4	100100	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													111.00	50		50					122.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	052	0		29	10	S5884_052_0	1	2	Preferred Brand	3	4	010001	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													63.00	50		50					69.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	053	0		29	10	S5884_053_0	1	2	Preferred Brand	3	4	010001	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													66.00	50		50					73.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	053	0		29	10	S5884_053_0	1	1	Preferred Generic	3	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										4.00		12.00						9.00		27.00													0.00		0.00					4.00		12.00				9.00					4.00			4.00		1		
S5884	053	0		29	10	S5884_053_0	1	4	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													855.00	33							855.00	33														33							33					33				33			33			
S5884	053	0		29	10	S5884_053_0	1	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										72.00		216.00						77.00		231.00													72.00		206.00					72.00		216.00				77.00					72.00			72.00				
S5884	053	0		29	10	S5884_053_0	1	2	Preferred Brand	1	4	010001	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										39.00		117.00						44.00		132.00													39.00		107.00					39.00		117.00				44.00					39.00			39.00				
S5884	053	0		29	10	S5884_053_0	1	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										4.00		12.00						9.00		27.00													0.00		0.00					4.00		12.00				9.00					4.00			4.00				
S5884	053	0		29	10	S5884_053_0	1	3	Non-Preferred Brand	3	4	100100	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													127.00	50		50					140.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	058	0		29	10	S5884_058_0	1	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						10.00		30.00													0.00		0.00					5.00		15.00				10.00					5.00			5.00				
S5884	058	0		29	10	S5884_058_0	1	2	Preferred Brand	1	4	010001	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										37.00		111.00						42.00		126.00													37.00		101.00					37.00		111.00				42.00					37.00			37.00				
S5884	058	0		29	10	S5884_058_0	1	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										71.00		213.00						76.00		228.00													71.00		203.00					71.00		213.00				76.00					71.00			71.00				
S5884	058	0		29	10	S5884_058_0	1	4	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													569.00	33							569.00	33														33							33					33				33			33			
S5884	058	0		29	10	S5884_058_0	1	1	Preferred Generic	3	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						10.00		30.00													0.00		0.00					5.00		15.00				10.00					5.00			5.00		1		
S5884	058	0		29	10	S5884_058_0	1	3	Non-Preferred Brand	3	4	100100	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													115.00	50		50					127.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	058	0		29	10	S5884_058_0	1	2	Preferred Brand	3	4	010001	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													68.00	50		50					75.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	059	0		29	10	S5884_059_0	1	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						10.00		30.00													0.00		0.00					5.00		15.00				10.00					5.00			5.00				
S5884	059	0		29	10	S5884_059_0	1	2	Preferred Brand	1	4	010001	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										37.00		111.00						42.00		126.00													37.00		101.00					37.00		111.00				42.00					37.00			37.00				
S5884	059	0		29	10	S5884_059_0	1	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										71.00		213.00						76.00		228.00													71.00		203.00					71.00		213.00				76.00					71.00			71.00				
S5884	059	0		29	10	S5884_059_0	1	4	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													1041.00	33							1041.00	33														33							33					33				33			33			
S5884	059	0		29	10	S5884_059_0	1	1	Preferred Generic	3	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						10.00		30.00													0.00		0.00					5.00		15.00				10.00					5.00			5.00		1		
S5884	059	0		29	10	S5884_059_0	1	2	Preferred Brand	3	4	010001	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													66.00	50		50					73.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	059	0		29	10	S5884_059_0	1	3	Non-Preferred Brand	3	4	100100	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													106.00	50		50					117.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	060	0		29	10	S5884_060_0	1	2	Preferred Brand	3	4	010001	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													69.00	50		50					76.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	060	0		29	10	S5884_060_0	1	4	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													612.00	33							612.00	33														33							33					33				33			33			
S5884	060	0		29	10	S5884_060_0	1	3	Non-Preferred Brand	1	4	100100	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										69.00		207.00						74.00		222.00													69.00		197.00					69.00		207.00				74.00					69.00			69.00				
S5884	060	0		29	10	S5884_060_0	1	2	Preferred Brand	1	4	010001	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										37.00		111.00						42.00		126.00													37.00		101.00					37.00		111.00				42.00					37.00			37.00				
S5884	060	0		29	10	S5884_060_0	1	3	Non-Preferred Brand	3	4	100100	1	1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													115.00	50		50					126.00	55		55												50		50					55		55			55				50			50	2	1	
S5884	060	0		29	10	S5884_060_0	1	1	Preferred Generic	3	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						10.00		30.00													0.00		0.00					5.00		15.00				10.00					5.00			5.00		1		
S5884	060	0		29	10	S5884_060_0	1	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						10.00		30.00													0.00		0.00					5.00		15.00				10.00					5.00			5.00				
S5884	062	0		29	10	S5884_062_0	2	3	Preferred Brand	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										40.00		120.00						40.00		120.00													40.00		110.00					40.00		120.00				40.00					40.00			40.00				
S5884	062	0		29	10	S5884_062_0	2	2	Non-Preferred Generic	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						7.00		21.00													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
S5884	062	0		29	10	S5884_062_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										2.00		6.00						5.00		15.00													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
S5884	062	0		29	10	S5884_062_0	2	5	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													746.00	33							739.00	33														33							33					33				33			33			
S5884	062	0		29	10	S5884_062_0	2	4	Non-Preferred Brand	1	4	110000	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										90.00		270.00						90.00		270.00													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
S5884	065	0		29	10	S5884_065_0	2	5	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													617.00	33							609.00	33														33							33					33				33			33			
S5884	065	0		29	10	S5884_065_0	2	4	Non-Preferred Brand	1	4	110000	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										90.00		270.00						90.00		270.00													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
S5884	065	0		29	10	S5884_065_0	2	3	Preferred Brand	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										41.00		123.00						41.00		123.00													41.00		113.00					41.00		123.00				41.00					41.00			41.00				
S5884	065	0		29	10	S5884_065_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										2.00		6.00						5.00		15.00													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
S5884	065	0		29	10	S5884_065_0	2	2	Non-Preferred Generic	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						7.00		21.00													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
S5884	066	0		29	10	S5884_066_0	2	4	Non-Preferred Brand	1	4	110000	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										90.00		270.00						90.00		270.00													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
S5884	066	0		29	10	S5884_066_0	2	3	Preferred Brand	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										42.00		126.00						42.00		126.00													42.00		116.00					42.00		126.00				42.00					42.00			42.00				
S5884	066	0		29	10	S5884_066_0	2	2	Non-Preferred Generic	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						7.00		21.00													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
S5884	066	0		29	10	S5884_066_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										2.00		6.00						5.00		15.00													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
S5884	066	0		29	10	S5884_066_0	2	5	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													718.00	33							709.00	33														33							33					33				33			33			
S5884	071	0		29	10	S5884_071_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										2.00		6.00						5.00		15.00													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
S5884	071	0		29	10	S5884_071_0	2	2	Non-Preferred Generic	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						7.00		21.00													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
S5884	071	0		29	10	S5884_071_0	2	5	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													806.00	33							796.00	33														33							33					33				33			33			
S5884	071	0		29	10	S5884_071_0	2	4	Non-Preferred Brand	1	4	110000	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										90.00		270.00						90.00		270.00													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
S5884	071	0		29	10	S5884_071_0	2	3	Preferred Brand	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										41.00		123.00						41.00		123.00													41.00		113.00					41.00		123.00				41.00					41.00			41.00				
S5884	072	0		29	10	S5884_072_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										2.00		6.00						5.00		15.00													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
S5884	072	0		29	10	S5884_072_0	2	2	Non-Preferred Generic	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						7.00		21.00													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
S5884	072	0		29	10	S5884_072_0	2	3	Preferred Brand	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										41.00		123.00						41.00		123.00													41.00		113.00					41.00		123.00				41.00					41.00			41.00				
S5884	072	0		29	10	S5884_072_0	2	4	Non-Preferred Brand	1	4	110000	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										90.00		270.00						90.00		270.00													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
S5884	072	0		29	10	S5884_072_0	2	5	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													755.00	33							749.00	33														33							33					33				33			33			
S5884	073	0		29	10	S5884_073_0	2	2	Non-Preferred Generic	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						7.00		21.00													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
S5884	073	0		29	10	S5884_073_0	2	3	Preferred Brand	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										41.00		123.00						41.00		123.00													41.00		113.00					41.00		123.00				41.00					41.00			41.00				
S5884	073	0		29	10	S5884_073_0	2	4	Non-Preferred Brand	1	4	110000	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										90.00		270.00						90.00		270.00													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
S5884	073	0		29	10	S5884_073_0	2	5	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													757.00	33							746.00	33														33							33					33				33			33			
S5884	073	0		29	10	S5884_073_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										2.00		6.00						5.00		15.00													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
S5884	074	0		29	10	S5884_074_0	2	4	Non-Preferred Brand	1	4	110000	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										90.00		270.00						90.00		270.00													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
S5884	074	0		29	10	S5884_074_0	2	3	Preferred Brand	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										43.00		129.00						43.00		129.00													43.00		119.00					43.00		129.00				43.00					43.00			43.00				
S5884	074	0		29	10	S5884_074_0	2	2	Non-Preferred Generic	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						7.00		21.00													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
S5884	074	0		29	10	S5884_074_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										2.00		6.00						5.00		15.00													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
S5884	074	0		29	10	S5884_074_0	2	5	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													730.00	33							715.00	33														33							33					33				33			33			
S5884	076	0		29	10	S5884_076_0	1	4	Non-Preferred Brand	1	4	110000	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										90.00		270.00						90.00		270.00													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
S5884	076	0		29	10	S5884_076_0	1	5	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													837.00	33							818.00	33														33							33					33				33			33			
S5884	076	0		29	10	S5884_076_0	1	3	Preferred Brand	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										41.00		123.00						41.00		123.00													41.00		113.00					41.00		123.00				41.00					41.00			41.00				
S5884	076	0		29	10	S5884_076_0	1	2	Non-Preferred Generic	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						7.00		21.00													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
S5884	076	0		29	10	S5884_076_0	1	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										2.00		6.00						5.00		15.00													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
S5884	077	0		29	10	S5884_077_0	1	5	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													1040.00	33							1018.00	33														33							33					33				33			33			
S5884	077	0		29	10	S5884_077_0	1	4	Non-Preferred Brand	1	4	110000	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										90.00		270.00						90.00		270.00													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
S5884	077	0		29	10	S5884_077_0	1	3	Preferred Brand	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										38.00		114.00						38.00		114.00													38.00		104.00					38.00		114.00				38.00					38.00			38.00				
S5884	077	0		29	10	S5884_077_0	1	2	Non-Preferred Generic	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						7.00		21.00													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
S5884	077	0		29	10	S5884_077_0	1	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										2.00		6.00						5.00		15.00													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
S5884	078	0		29	10	S5884_078_0	1	5	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													778.00	33							771.00	33														33							33					33				33			33			
S5884	078	0		29	10	S5884_078_0	1	4	Non-Preferred Brand	1	4	110000	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										90.00		270.00						90.00		270.00													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
S5884	078	0		29	10	S5884_078_0	1	3	Preferred Brand	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										38.00		114.00						38.00		114.00													38.00		104.00					38.00		114.00				38.00					38.00			38.00				
S5884	078	0		29	10	S5884_078_0	1	2	Non-Preferred Generic	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						7.00		21.00													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
S5884	078	0		29	10	S5884_078_0	1	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										2.00		6.00						5.00		15.00													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
S5884	083	0		29	10	S5884_083_0	1	5	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													852.00	33							835.00	33														33							33					33				33			33			
S5884	083	0		29	10	S5884_083_0	1	4	Non-Preferred Brand	1	4	110000	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										90.00		270.00						90.00		270.00													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
S5884	083	0		29	10	S5884_083_0	1	3	Preferred Brand	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										38.00		114.00						38.00		114.00													38.00		104.00					38.00		114.00				38.00					38.00			38.00				
S5884	083	0		29	10	S5884_083_0	1	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										2.00		6.00						5.00		15.00													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
S5884	083	0		29	10	S5884_083_0	1	2	Non-Preferred Generic	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						7.00		21.00													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
S5884	085	0		29	10	S5884_085_0	1	4	Non-Preferred Brand	1	4	110000	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										90.00		270.00						90.00		270.00													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
S5884	085	0		29	10	S5884_085_0	1	3	Preferred Brand	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										43.00		129.00						43.00		129.00													43.00		119.00					43.00		129.00				43.00					43.00			43.00				
S5884	085	0		29	10	S5884_085_0	1	2	Non-Preferred Generic	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						7.00		21.00													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
S5884	085	0		29	10	S5884_085_0	1	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										2.00		6.00						5.00		15.00													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
S5884	085	0		29	10	S5884_085_0	1	5	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													805.00	33							795.00	33														33							33					33				33			33			
S5884	086	0		29	10	S5884_086_0	1	5	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													778.00	33							770.00	33														33							33					33				33			33			
S5884	086	0		29	10	S5884_086_0	1	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										2.00		6.00						5.00		15.00													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
S5884	086	0		29	10	S5884_086_0	1	2	Non-Preferred Generic	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						7.00		21.00													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
S5884	086	0		29	10	S5884_086_0	1	3	Preferred Brand	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										43.00		129.00						43.00		129.00													43.00		119.00					43.00		129.00				43.00					43.00			43.00				
S5884	086	0		29	10	S5884_086_0	1	4	Non-Preferred Brand	1	4	110000	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										90.00		270.00						90.00		270.00													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
S5884	087	0		29	10	S5884_087_0	1	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										2.00		6.00						5.00		15.00													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
S5884	087	0		29	10	S5884_087_0	1	2	Non-Preferred Generic	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						7.00		21.00													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
S5884	087	0		29	10	S5884_087_0	1	3	Preferred Brand	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										44.00		132.00						44.00		132.00													44.00		122.00					44.00		132.00				44.00					44.00			44.00				
S5884	087	0		29	10	S5884_087_0	1	4	Non-Preferred Brand	1	4	110000	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										90.00		270.00						90.00		270.00													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
S5884	087	0		29	10	S5884_087_0	1	5	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													827.00	33							823.00	33														33							33					33				33			33			
S5884	089	0		29	10	S5884_089_0	1	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										2.00		6.00						5.00		15.00													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
S5884	089	0		29	10	S5884_089_0	1	2	Non-Preferred Generic	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						7.00		21.00													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
S5884	089	0		29	10	S5884_089_0	1	3	Preferred Brand	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										42.00		126.00						42.00		126.00													42.00		116.00					42.00		126.00				42.00					42.00			42.00				
S5884	089	0		29	10	S5884_089_0	1	4	Non-Preferred Brand	1	4	110000	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										90.00		270.00						90.00		270.00													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
S5884	089	0		29	10	S5884_089_0	1	5	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													799.00	33							783.00	33														33							33					33				33			33			
S5884	092	0		29	10	S5884_092_0	2	5	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													624.00	33							619.00	33														33							33					33				33			33			
S5884	092	0		29	10	S5884_092_0	2	4	Non-Preferred Brand	1	4	110000	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										90.00		270.00						90.00		270.00													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
S5884	092	0		29	10	S5884_092_0	2	3	Preferred Brand	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										43.00		129.00						43.00		129.00													43.00		119.00					43.00		129.00				43.00					43.00			43.00				
S5884	092	0		29	10	S5884_092_0	2	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										2.00		6.00						5.00		15.00													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
S5884	092	0		29	10	S5884_092_0	2	2	Non-Preferred Generic	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						7.00		21.00													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
S5884	093	0		29	10	S5884_093_0	1	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										2.00		6.00						5.00		15.00													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
S5884	093	0		29	10	S5884_093_0	1	2	Non-Preferred Generic	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						7.00		21.00													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
S5884	093	0		29	10	S5884_093_0	1	3	Preferred Brand	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										45.00		135.00						45.00		135.00													45.00		125.00					45.00		135.00				45.00					45.00			45.00				
S5884	093	0		29	10	S5884_093_0	1	4	Non-Preferred Brand	1	4	110000	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										95.00		285.00						95.00		285.00													95.00		275.00					95.00		285.00				95.00					95.00			95.00				
S5884	093	0		29	10	S5884_093_0	1	5	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													578.00	33							572.00	33														33							33					33				33			33			
S5884	094	0		29	10	S5884_094_0	1	4	Non-Preferred Brand	1	4	110000	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										90.00		270.00						90.00		270.00													90.00		260.00					90.00		270.00				90.00					90.00			90.00				
S5884	094	0		29	10	S5884_094_0	1	3	Preferred Brand	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										41.00		123.00						41.00		123.00													41.00		113.00					41.00		123.00				41.00					41.00			41.00				
S5884	094	0		29	10	S5884_094_0	1	2	Non-Preferred Generic	1	4	000101	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						7.00		21.00													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
S5884	094	0		29	10	S5884_094_0	1	1	Preferred Generic	1	4	001010	1	2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										2.00		6.00						5.00		15.00													0.00		0.00					5.00		15.00				5.00					5.00			5.00				
S5884	094	0		29	10	S5884_094_0	1	5	Specialty Tier	1	4	010010	1	1	100010010010000100100101				30			30							30			30			30		31		31	14													891.00	33							883.00	33														33							33					33				33			33			
S5884	101	0		29	10	S5884_101_0	4	1	Preferred Generic	1	2	001010		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										1.00		3.00						10.00		30.00													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
S5884	101	0		29	10	S5884_101_0	4	5	Specialty Tier	1	2	010010		1	100010010010000100100101				30			30							30			30			30		31		31	14													608.00	25							603.00	25														25							25					25				25			25			
S5884	101	0		29	10	S5884_101_0	4	4	Non-Preferred Brand	1	2	110000		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													91.00	35		35					104.00	40		40												35		35					40		40			40				40			40			
S5884	101	0		29	10	S5884_101_0	4	3	Preferred Brand	1	2	000101		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													20.00	20		20					25.00	25		25												20		20					25		25			25				25			25			
S5884	101	0		29	10	S5884_101_0	4	2	Non-Preferred Generic	1	2	000101		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						20.00		60.00													0.00		0.00					20.00		60.00				20.00					20.00			20.00				
S5884	102	0		29	10	S5884_102_0	4	1	Preferred Generic	1	2	001010		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										1.00		3.00						10.00		30.00													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
S5884	102	0		29	10	S5884_102_0	4	2	Non-Preferred Generic	1	2	000101		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										4.00		12.00						21.00		63.00													0.00		0.00					21.00		63.00				21.00					21.00			21.00				
S5884	102	0		29	10	S5884_102_0	4	5	Specialty Tier	1	2	010010		1	100010010010000100100101				30			30							30			30			30		31		31	14													522.00	25							516.00	25														25							25					25				25			25			
S5884	102	0		29	10	S5884_102_0	4	4	Non-Preferred Brand	1	2	110000		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													102.00	30		30					104.00	31		31												30		30					31		31			31				31			31			
S5884	102	0		29	10	S5884_102_0	4	3	Preferred Brand	1	2	000101		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													19.00	20		20					25.00	25		25												20		20					25		25			25				25			25			
S5884	103	0		29	10	S5884_103_0	4	1	Preferred Generic	1	2	001010		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										1.00		3.00						10.00		30.00													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
S5884	103	0		29	10	S5884_103_0	4	2	Non-Preferred Generic	1	2	000101		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						18.00		54.00													0.00		0.00					18.00		54.00				18.00					18.00			18.00				
S5884	103	0		29	10	S5884_103_0	4	5	Specialty Tier	1	2	010010		1	100010010010000100100101				30			30							30			30			30		31		31	14													435.00	25							428.00	25														25							25					25				25			25			
S5884	103	0		29	10	S5884_103_0	4	3	Preferred Brand	1	2	000101		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													19.00	20		20					24.00	25		25												20		20					25		25			25				25			25			
S5884	103	0		29	10	S5884_103_0	4	4	Non-Preferred Brand	1	2	110000		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													97.00	34		34					105.00	37		37												34		34					37		37			37				37			37			
S5884	104	0		29	10	S5884_104_0	4	5	Specialty Tier	1	2	010010		1	100010010010000100100101				30			30							30			30			30		31		31	14													487.00	25							481.00	25														25							25					25				25			25			
S5884	104	0		29	10	S5884_104_0	4	4	Non-Preferred Brand	1	2	110000		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													94.00	35		35					103.00	39		39												35		35					39		39			39				39			39			
S5884	104	0		29	10	S5884_104_0	4	2	Non-Preferred Generic	1	2	000101		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						19.00		57.00													0.00		0.00					19.00		57.00				19.00					19.00			19.00				
S5884	104	0		29	10	S5884_104_0	4	3	Preferred Brand	1	2	000101		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													19.00	20		20					24.00	25		25												20		20					25		25			25				25			25			
S5884	104	0		29	10	S5884_104_0	4	1	Preferred Generic	1	2	001010		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										1.00		3.00						10.00		30.00													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
S5884	105	0		29	10	S5884_105_0	4	4	Non-Preferred Brand	1	2	110000		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													98.00	32		32					105.00	35		35												32		32					35		35			35				35			35			
S5884	105	0		29	10	S5884_105_0	4	3	Preferred Brand	1	2	000101		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													19.00	20		20					25.00	25		25												20		20					25		25			25				25			25			
S5884	105	0		29	10	S5884_105_0	4	2	Non-Preferred Generic	1	2	000101		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										4.00		12.00						16.00		48.00													0.00		0.00					16.00		48.00				16.00					16.00			16.00				
S5884	105	0		29	10	S5884_105_0	4	1	Preferred Generic	1	2	001010		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										1.00		3.00						7.00		21.00													0.00		0.00					7.00		21.00				7.00					7.00			7.00				
S5884	105	0		29	10	S5884_105_0	4	5	Specialty Tier	1	2	010010		1	100010010010000100100101				30			30							30			30			30		31		31	14													449.00	25							444.00	25														25							25					25				25			25			
S5884	106	0		29	10	S5884_106_0	4	2	Non-Preferred Generic	1	2	000101		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										4.00		12.00						18.00		54.00													0.00		0.00					18.00		54.00				18.00					18.00			18.00				
S5884	106	0		29	10	S5884_106_0	4	1	Preferred Generic	1	2	001010		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										1.00		3.00						10.00		30.00													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
S5884	106	0		29	10	S5884_106_0	4	4	Non-Preferred Brand	1	2	110000		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													89.00	35		35					104.00	42		42												35		35					42		42			42				42			42			
S5884	106	0		29	10	S5884_106_0	4	5	Specialty Tier	1	2	010010		1	100010010010000100100101				30			30							30			30			30		31		31	14													514.00	25							505.00	25														25							25					25				25			25			
S5884	106	0		29	10	S5884_106_0	4	3	Preferred Brand	1	2	000101		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													16.00	20		20					21.00	25		25												20		20					25		25			25				25			25			
S5884	107	0		29	10	S5884_107_0	4	4	Non-Preferred Brand	1	2	110000		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													98.00	35		35					105.00	38		38												35		35					38		38			38				38			38			
S5884	107	0		29	10	S5884_107_0	4	5	Specialty Tier	1	2	010010		1	100010010010000100100101				30			30							30			30			30		31		31	14													511.00	25							504.00	25														25							25					25				25			25			
S5884	107	0		29	10	S5884_107_0	4	2	Non-Preferred Generic	1	2	000101		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						22.00		66.00													0.00		0.00					22.00		66.00				22.00					22.00			22.00				
S5884	107	0		29	10	S5884_107_0	4	1	Preferred Generic	1	2	001010		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										1.00		3.00						10.00		30.00													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
S5884	107	0		29	10	S5884_107_0	4	3	Preferred Brand	1	2	000101		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													19.00	20		20					25.00	25		25												20		20					25		25			25				25			25			
S5884	108	0		29	10	S5884_108_0	4	2	Non-Preferred Generic	1	2	000101		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										4.00		12.00						14.00		42.00													0.00		0.00					14.00		42.00				14.00					14.00			14.00				
S5884	108	0		29	10	S5884_108_0	4	3	Preferred Brand	1	2	000101		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													18.00	20		20					23.00	25		25												20		20					25		25			25				25			25			
S5884	108	0		29	10	S5884_108_0	4	4	Non-Preferred Brand	1	2	110000		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													87.00	35		35					105.00	43		43												35		35					43		43			43				43			43			
S5884	108	0		29	10	S5884_108_0	4	5	Specialty Tier	1	2	010010		1	100010010010000100100101				30			30							30			30			30		31		31	14													493.00	25							486.00	25														25							25					25				25			25			
S5884	108	0		29	10	S5884_108_0	4	1	Preferred Generic	1	2	001010		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										1.00		3.00						10.00		30.00													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
S5884	109	0		29	10	S5884_109_0	3	4	Non-Preferred Brand	1	2	110000		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													70.00	35		35					98.00	50		50												35		35					50		50			50				50			50			
S5884	109	0		29	10	S5884_109_0	3	3	Preferred Brand	1	2	000101		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													17.00	20		20					22.00	25		25												20		20					25		25			25				25			25			
S5884	109	0		29	10	S5884_109_0	3	2	Non-Preferred Generic	1	2	000101		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						14.00		42.00													0.00		0.00					14.00		42.00				14.00					14.00			14.00				
S5884	109	0		29	10	S5884_109_0	3	1	Preferred Generic	1	2	001010		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										1.00		3.00						10.00		30.00													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
S5884	109	0		29	10	S5884_109_0	3	5	Specialty Tier	1	2	010010		1	100010010010000100100101				30			30							30			30			30		31		31	14													522.00	25							512.00	25														25							25					25				25			25			
S5884	110	0		29	10	S5884_110_0	4	1	Preferred Generic	1	2	001010		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										1.00		3.00						8.00		24.00													0.00		0.00					8.00		24.00				8.00					8.00			8.00				
S5884	110	0		29	10	S5884_110_0	4	2	Non-Preferred Generic	1	2	000101		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						15.00		45.00													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
S5884	110	0		29	10	S5884_110_0	4	3	Preferred Brand	1	2	000101		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													18.00	20		20					23.00	25		25												20		20					25		25			25				25			25			
S5884	110	0		29	10	S5884_110_0	4	4	Non-Preferred Brand	1	2	110000		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													94.00	30		30					103.00	33		33												30		30					33		33			33				33			33			
S5884	110	0		29	10	S5884_110_0	4	5	Specialty Tier	1	2	010010		1	100010010010000100100101				30			30							30			30			30		31		31	14													532.00	25							525.00	25														25							25					25				25			25			
S5884	111	0		29	10	S5884_111_0	4	5	Specialty Tier	1	2	010010		1	100010010010000100100101				30			30							30			30			30		31		31	14													609.00	25							606.00	25														25							25					25				25			25			
S5884	111	0		29	10	S5884_111_0	4	4	Non-Preferred Brand	1	2	110000		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													93.00	35		35					105.00	40		40												35		35					40		40			40				40			40			
S5884	111	0		29	10	S5884_111_0	4	3	Preferred Brand	1	2	000101		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													18.00	20		20					24.00	25		25												20		20					25		25			25				25			25			
S5884	111	0		29	10	S5884_111_0	4	2	Non-Preferred Generic	1	2	000101		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						18.00		54.00													0.00		0.00					18.00		54.00				18.00					18.00			18.00				
S5884	111	0		29	10	S5884_111_0	4	1	Preferred Generic	1	2	001010		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										1.00		3.00						10.00		30.00													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
S5884	112	0		29	10	S5884_112_0	4	1	Preferred Generic	1	2	001010		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										1.00		3.00						6.00		18.00													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
S5884	112	0		29	10	S5884_112_0	4	2	Non-Preferred Generic	1	2	000101		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										4.00		12.00						12.00		36.00													0.00		0.00					12.00		36.00				12.00					12.00			12.00				
S5884	112	0		29	10	S5884_112_0	4	5	Specialty Tier	1	2	010010		1	100010010010000100100101				30			30							30			30			30		31		31	14													507.00	25							502.00	25														25							25					25				25			25			
S5884	112	0		29	10	S5884_112_0	4	4	Non-Preferred Brand	1	2	110000		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													97.00	32		32					105.00	35		35												32		32					35		35			35				35			35			
S5884	112	0		29	10	S5884_112_0	4	3	Preferred Brand	1	2	000101		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													17.00	20		20					22.00	25		25												20		20					25		25			25				25			25			
S5884	113	0		29	10	S5884_113_0	4	5	Specialty Tier	1	2	010010		1	100010010010000100100101				30			30							30			30			30		31		31	14													574.00	25							566.00	25														25							25					25				25			25			
S5884	113	0		29	10	S5884_113_0	4	4	Non-Preferred Brand	1	2	110000		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													88.00	35		35					105.00	42		42												35		35					42		42			42				42			42			
S5884	113	0		29	10	S5884_113_0	4	3	Preferred Brand	1	2	000101		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													17.00	20		20					22.00	25		25												20		20					25		25			25				25			25			
S5884	113	0		29	10	S5884_113_0	4	2	Non-Preferred Generic	1	2	000101		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						16.00		48.00													0.00		0.00					16.00		48.00				16.00					16.00			16.00				
S5884	113	0		29	10	S5884_113_0	4	1	Preferred Generic	1	2	001010		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										1.00		3.00						10.00		30.00													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
S5884	114	0		29	10	S5884_114_0	3	1	Preferred Generic	1	2	001010		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										1.00		3.00						6.00		18.00													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
S5884	114	0		29	10	S5884_114_0	3	2	Non-Preferred Generic	1	2	000101		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										3.00		9.00						10.00		30.00													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
S5884	114	0		29	10	S5884_114_0	3	3	Preferred Brand	1	2	000101		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													20.00	20		20					26.00	25		25												20		20					25		25			25				25			25			
S5884	114	0		29	10	S5884_114_0	3	4	Non-Preferred Brand	1	2	110000		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													94.00	35		35					103.00	39		39												35		35					39		39			39				39			39			
S5884	114	0		29	10	S5884_114_0	3	5	Specialty Tier	1	2	010010		1	100010010010000100100101				30			30							30			30			30		31		31	14													459.00	25							454.00	25														25							25					25				25			25			
S5884	115	0		29	10	S5884_115_0	4	5	Specialty Tier	1	2	010010		1	100010010010000100100101				30			30							30			30			30		31		31	14													666.00	25							659.00	25														25							25					25				25			25			
S5884	115	0		29	10	S5884_115_0	4	1	Preferred Generic	1	2	001010		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										1.00		3.00						10.00		30.00													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
S5884	115	0		29	10	S5884_115_0	4	2	Non-Preferred Generic	1	2	000101		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						17.00		51.00													0.00		0.00					17.00		51.00				17.00					17.00			17.00				
S5884	115	0		29	10	S5884_115_0	4	3	Preferred Brand	1	2	000101		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													20.00	20		20					26.00	25		25												20		20					25		25			25				25			25			
S5884	115	0		29	10	S5884_115_0	4	4	Non-Preferred Brand	1	2	110000		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													96.00	30		30					105.00	33		33												30		30					33		33			33				33			33			
S5884	116	0		29	10	S5884_116_0	3	1	Preferred Generic	1	2	001010		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										1.00		3.00						6.00		18.00													0.00		0.00					6.00		18.00				6.00					6.00			6.00				
S5884	116	0		29	10	S5884_116_0	3	2	Non-Preferred Generic	1	2	000101		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										3.00		9.00						8.00		24.00													0.00		0.00					8.00		24.00				8.00					8.00			8.00				
S5884	116	0		29	10	S5884_116_0	3	5	Specialty Tier	1	2	010010		1	100010010010000100100101				30			30							30			30			30		31		31	14													759.00	25							746.00	25														25							25					25				25			25			
S5884	116	0		29	10	S5884_116_0	3	4	Non-Preferred Brand	1	2	110000		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													88.00	35		35					103.00	42		42												35		35					42		42			42				42			42			
S5884	116	0		29	10	S5884_116_0	3	3	Preferred Brand	1	2	000101		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													20.00	20		20					26.00	25		25												20		20					25		25			25				25			25			
S5884	131	0		29	10	S5884_131_0	3	2	Non-Preferred Generic	1	2	000101		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										4.00		12.00						15.00		45.00													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
S5884	131	0		29	10	S5884_131_0	3	3	Preferred Brand	1	2	000101		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													21.00	20		20					27.00	25		25												20		20					25		25			25				25			25			
S5884	131	0		29	10	S5884_131_0	3	4	Non-Preferred Brand	1	2	110000		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													95.00	35		35					105.00	39		39												35		35					39		39			39				39			39			
S5884	131	0		29	10	S5884_131_0	3	5	Specialty Tier	1	2	010010		1	100010010010000100100101				30			30							30			30			30		31		31	14													495.00	25							487.00	25														25							25					25				25			25			
S5884	131	0		29	10	S5884_131_0	3	1	Preferred Generic	1	2	001010		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										1.00		3.00						10.00		30.00													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
S5884	132	0		29	10	S5884_132_0	3	4	Non-Preferred Brand	1	2	110000		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													96.00	35		35					103.00	38		38												35		35					38		38			38				38			38			
S5884	132	0		29	10	S5884_132_0	3	3	Preferred Brand	1	2	000101		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													18.00	20		20					24.00	25		25												20		20					25		25			25				25			25			
S5884	132	0		29	10	S5884_132_0	3	2	Non-Preferred Generic	1	2	000101		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										4.00		12.00						14.00		42.00													0.00		0.00					14.00		42.00				14.00					14.00			14.00				
S5884	132	0		29	10	S5884_132_0	3	1	Preferred Generic	1	2	001010		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										1.00		3.00						8.00		24.00													0.00		0.00					8.00		24.00				8.00					8.00			8.00				
S5884	132	0		29	10	S5884_132_0	3	5	Specialty Tier	1	2	010010		1	100010010010000100100101				30			30							30			30			30		31		31	14													471.00	25							464.00	25														25							25					25				25			25			
S5884	133	0		29	10	S5884_133_0	3	4	Non-Preferred Brand	1	2	110000		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													97.00	34		34					103.00	37		37												34		34					37		37			37				37			37			
S5884	133	0		29	10	S5884_133_0	3	5	Specialty Tier	1	2	010010		1	100010010010000100100101				30			30							30			30			30		31		31	14													485.00	25							475.00	25														25							25					25				25			25			
S5884	133	0		29	10	S5884_133_0	3	3	Preferred Brand	1	2	000101		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													19.00	20		20					24.00	25		25												20		20					25		25			25				25			25			
S5884	133	0		29	10	S5884_133_0	3	2	Non-Preferred Generic	1	2	000101		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										4.00		12.00						15.00		45.00													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
S5884	133	0		29	10	S5884_133_0	3	1	Preferred Generic	1	2	001010		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										1.00		3.00						8.00		24.00													0.00		0.00					8.00		24.00				8.00					8.00			8.00				
S5884	134	0		29	10	S5884_134_0	3	3	Preferred Brand	1	2	000101		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													18.00	20		20					23.00	25		25												20		20					25		25			25				25			25			
S5884	134	0		29	10	S5884_134_0	3	2	Non-Preferred Generic	1	2	000101		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						19.00		57.00													0.00		0.00					19.00		57.00				19.00					19.00			19.00				
S5884	134	0		29	10	S5884_134_0	3	5	Specialty Tier	1	2	010010		1	100010010010000100100101				30			30							30			30			30		31		31	14													520.00	25							512.00	25														25							25					25				25			25			
S5884	134	0		29	10	S5884_134_0	3	4	Non-Preferred Brand	1	2	110000		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													80.00	35		35					105.00	47		47												35		35					47		47			47				47			47			
S5884	134	0		29	10	S5884_134_0	3	1	Preferred Generic	1	2	001010		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										1.00		3.00						10.00		30.00													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
S5884	135	0		29	10	S5884_135_0	4	4	Non-Preferred Brand	1	2	110000		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													90.00	35		35					104.00	41		41												35		35					41		41			41				41			41			
S5884	135	0		29	10	S5884_135_0	4	2	Non-Preferred Generic	1	2	000101		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						20.00		60.00													0.00		0.00					20.00		60.00				20.00					20.00			20.00				
S5884	135	0		29	10	S5884_135_0	4	1	Preferred Generic	1	2	001010		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										1.00		3.00						10.00		30.00													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
S5884	135	0		29	10	S5884_135_0	4	5	Specialty Tier	1	2	010010		1	100010010010000100100101				30			30							30			30			30		31		31	14													510.00	25							506.00	25														25							25					25				25			25			
S5884	135	0		29	10	S5884_135_0	4	3	Preferred Brand	1	2	000101		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													18.00	20		20					23.00	25		25												20		20					25		25			25				25			25			
S5884	136	0		29	10	S5884_136_0	4	3	Preferred Brand	1	2	000101		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													18.00	20		20					23.00	25		25												20		20					25		25			25				25			25			
S5884	136	0		29	10	S5884_136_0	4	4	Non-Preferred Brand	1	2	110000		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													76.00	35		35					104.00	48		48												35		35					48		48			48				48			48			
S5884	136	0		29	10	S5884_136_0	4	5	Specialty Tier	1	2	010010		1	100010010010000100100101				30			30							30			30			30		31		31	14													619.00	25							611.00	25														25							25					25				25			25			
S5884	136	0		29	10	S5884_136_0	4	1	Preferred Generic	1	2	001010		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										1.00		3.00						10.00		30.00													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
S5884	136	0		29	10	S5884_136_0	4	2	Non-Preferred Generic	1	2	000101		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						22.00		66.00													0.00		0.00					22.00		66.00				22.00					22.00			22.00				
S5884	137	0		29	10	S5884_137_0	4	5	Specialty Tier	1	2	010010		1	100010010010000100100101				30			30							30			30			30		31		31	14													520.00	25							514.00	25														25							25					25				25			25			
S5884	137	0		29	10	S5884_137_0	4	4	Non-Preferred Brand	1	2	110000		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													97.00	32		32					105.00	35		35												32		32					35		35			35				35			35			
S5884	137	0		29	10	S5884_137_0	4	3	Preferred Brand	1	2	000101		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													17.00	20		20					23.00	25		25												20		20					25		25			25				25			25			
S5884	137	0		29	10	S5884_137_0	4	1	Preferred Generic	1	2	001010		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										1.00		3.00						10.00		30.00													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
S5884	137	0		29	10	S5884_137_0	4	2	Non-Preferred Generic	1	2	000101		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										4.00		12.00						20.00		60.00													0.00		0.00					20.00		60.00				20.00					20.00			20.00				
S5884	138	0		29	10	S5884_138_0	4	5	Specialty Tier	1	2	010010		1	100010010010000100100101				30			30							30			30			30		31		31	14													560.00	25							553.00	25														25							25					25				25			25			
S5884	138	0		29	10	S5884_138_0	4	4	Non-Preferred Brand	1	2	110000		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													82.00	35		35					104.00	45		45												35		35					45		45			45				45			45			
S5884	138	0		29	10	S5884_138_0	4	3	Preferred Brand	1	2	000101		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													19.00	20		20					24.00	25		25												20		20					25		25			25				25			25			
S5884	138	0		29	10	S5884_138_0	4	1	Preferred Generic	1	2	001010		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										1.00		3.00						10.00		30.00													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
S5884	138	0		29	10	S5884_138_0	4	2	Non-Preferred Generic	1	2	000101		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						18.00		54.00													0.00		0.00					18.00		54.00				18.00					18.00			18.00				
S5884	139	0		29	10	S5884_139_0	4	1	Preferred Generic	1	2	001010		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										1.00		3.00						10.00		30.00													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
S5884	139	0		29	10	S5884_139_0	4	5	Specialty Tier	1	2	010010		1	100010010010000100100101				30			30							30			30			30		31		31	14													682.00	25							670.00	25														25							25					25				25			25			
S5884	139	0		29	10	S5884_139_0	4	3	Preferred Brand	1	2	000101		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													18.00	20		20					23.00	25		25												20		20					25		25			25				25			25			
S5884	139	0		29	10	S5884_139_0	4	4	Non-Preferred Brand	1	2	110000		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													90.00	35		35					103.00	41		41												35		35					41		41			41				41			41			
S5884	139	0		29	10	S5884_139_0	4	2	Non-Preferred Generic	1	2	000101		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						33.00		99.00													0.00		0.00					33.00		99.00				33.00					33.00			33.00				
S5884	140	0		29	10	S5884_140_0	4	4	Non-Preferred Brand	1	2	110000		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													95.00	35		35					104.00	39		39												35		35					39		39			39				39			39			
S5884	140	0		29	10	S5884_140_0	4	3	Preferred Brand	1	2	000101		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													18.00	20		20					24.00	25		25												20		20					25		25			25				25			25			
S5884	140	0		29	10	S5884_140_0	4	2	Non-Preferred Generic	1	2	000101		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										4.00		12.00						15.00		45.00													0.00		0.00					15.00		45.00				15.00					15.00			15.00				
S5884	140	0		29	10	S5884_140_0	4	1	Preferred Generic	1	2	001010		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										1.00		3.00						10.00		30.00													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
S5884	140	0		29	10	S5884_140_0	4	5	Specialty Tier	1	2	010010		1	100010010010000100100101				30			30							30			30			30		31		31	14													484.00	25							476.00	25														25							25					25				25			25			
S5884	141	0		29	10	S5884_141_0	4	5	Specialty Tier	1	2	010010		1	100010010010000100100101				30			30							30			30			30		31		31	14													591.00	25							578.00	25														25							25					25				25			25			
S5884	141	0		29	10	S5884_141_0	4	4	Non-Preferred Brand	1	2	110000		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													69.00	35		35					97.00	50		50												35		35					50		50			50				50			50			
S5884	141	0		29	10	S5884_141_0	4	3	Preferred Brand	1	2	000101		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													18.00	20		20					23.00	25		25												20		20					25		25			25				25			25			
S5884	141	0		29	10	S5884_141_0	4	1	Preferred Generic	1	2	001010		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										1.00		3.00						10.00		30.00													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
S5884	141	0		29	10	S5884_141_0	4	2	Non-Preferred Generic	1	2	000101		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						14.00		42.00													0.00		0.00					14.00		42.00				14.00					14.00			14.00				
S5884	142	0		29	10	S5884_142_0	4	1	Preferred Generic	1	2	001010		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										1.00		3.00						10.00		30.00													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
S5884	142	0		29	10	S5884_142_0	4	2	Non-Preferred Generic	1	2	000101		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										4.00		12.00						14.00		42.00													0.00		0.00					14.00		42.00				14.00					14.00			14.00				
S5884	142	0		29	10	S5884_142_0	4	3	Preferred Brand	1	2	000101		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													18.00	20		20					23.00	25		25												20		20					25		25			25				25			25			
S5884	142	0		29	10	S5884_142_0	4	4	Non-Preferred Brand	1	2	110000		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													71.00	35		35					100.00	50		50												35		35					50		50			50				50			50			
S5884	142	0		29	10	S5884_142_0	4	5	Specialty Tier	1	2	010010		1	100010010010000100100101				30			30							30			30			30		31		31	14													628.00	25							615.00	25														25							25					25				25			25			
S5884	143	0		29	10	S5884_143_0	4	1	Preferred Generic	1	2	001010		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										1.00		3.00						10.00		30.00													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
S5884	143	0		29	10	S5884_143_0	4	2	Non-Preferred Generic	1	2	000101		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						17.00		51.00													0.00		0.00					17.00		51.00				17.00					17.00			17.00				
S5884	143	0		29	10	S5884_143_0	4	3	Preferred Brand	1	2	000101		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													19.00	20		20					25.00	25		25												20		20					25		25			25				25			25			
S5884	143	0		29	10	S5884_143_0	4	4	Non-Preferred Brand	1	2	110000		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													76.00	35		35					104.00	48		48												35		35					48		48			48				48			48			
S5884	143	0		29	10	S5884_143_0	4	5	Specialty Tier	1	2	010010		1	100010010010000100100101				30			30							30			30			30		31		31	14													512.00	25							510.00	25														25							25					25				25			25			
S5884	144	0		29	10	S5884_144_0	4	4	Non-Preferred Brand	1	2	110000		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													91.00	35		35					104.00	41		41												35		35					41		41			41				41			41			
S5884	144	0		29	10	S5884_144_0	4	3	Preferred Brand	1	2	000101		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													18.00	20		20					23.00	25		25												20		20					25		25			25				25			25			
S5884	144	0		29	10	S5884_144_0	4	2	Non-Preferred Generic	1	2	000101		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										4.00		12.00						14.00		42.00													0.00		0.00					14.00		42.00				14.00					14.00			14.00				
S5884	144	0		29	10	S5884_144_0	4	1	Preferred Generic	1	2	001010		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										1.00		3.00						10.00		30.00													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
S5884	144	0		29	10	S5884_144_0	4	5	Specialty Tier	1	2	010010		1	100010010010000100100101				30			30							30			30			30		31		31	14													559.00	25							549.00	25														25							25					25				25			25			
S5884	145	0		29	10	S5884_145_0	4	4	Non-Preferred Brand	1	2	110000		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													82.00	35		35					103.00	45		45												35		35					45		45			45				45			45			
S5884	145	0		29	10	S5884_145_0	4	3	Preferred Brand	1	2	000101		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													18.00	20		20					24.00	25		25												20		20					25		25			25				25			25			
S5884	145	0		29	10	S5884_145_0	4	2	Non-Preferred Generic	1	2	000101		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										4.00		12.00						18.00		54.00													0.00		0.00					18.00		54.00				18.00					18.00			18.00				
S5884	145	0		29	10	S5884_145_0	4	1	Preferred Generic	1	2	001010		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										1.00		3.00						10.00		30.00													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
S5884	145	0		29	10	S5884_145_0	4	5	Specialty Tier	1	2	010010		1	100010010010000100100101				30			30							30			30			30		31		31	14													636.00	25							625.00	25														25							25					25				25			25			
S5884	146	0		29	10	S5884_146_0	4	1	Preferred Generic	1	2	001010		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										1.00		3.00						10.00		30.00													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
S5884	146	0		29	10	S5884_146_0	4	2	Non-Preferred Generic	1	2	000101		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										5.00		15.00						18.00		54.00													0.00		0.00					18.00		54.00				18.00					18.00			18.00				
S5884	146	0		29	10	S5884_146_0	4	3	Preferred Brand	1	2	000101		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													17.00	20		20					22.00	25		25												20		20					25		25			25				25			25			
S5884	146	0		29	10	S5884_146_0	4	4	Non-Preferred Brand	1	2	110000		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													73.00	35		35					104.00	50		50												35		35					50		50			50				50			50			
S5884	146	0		29	10	S5884_146_0	4	5	Specialty Tier	1	2	010010		1	100010010010000100100101				30			30							30			30			30		31		31	14													489.00	25							484.00	25														25							25					25				25			25			
S5884	147	0		29	10	S5884_147_0	4	1	Preferred Generic	1	2	001010		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										1.00		3.00						10.00		30.00													0.00		0.00					10.00		30.00				10.00					10.00			10.00				
S5884	147	0		29	10	S5884_147_0	4	2	Non-Preferred Generic	1	2	000101		2	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14										4.00		12.00						14.00		42.00													0.00		0.00					14.00		42.00				14.00					14.00			14.00				
S5884	147	0		29	10	S5884_147_0	4	3	Preferred Brand	1	2	000101		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													16.00	20		20					22.00	25		25												20		20					25		25			25				25			25			
S5884	147	0		29	10	S5884_147_0	4	4	Non-Preferred Brand	1	2	110000		1	100010110110000101101101				30		90	30		90	2				30		90	30		90	30		31		31	14													73.00	35		35					102.00	50		50												35		35					50		50			50				50			50			
S5884	147	0		29	10	S5884_147_0	4	5	Specialty Tier	1	2	010010		1	100010010010000100100101				30			30							30			30			30		31		31	14													444.00	25							436.00	25														25							25					25				25			25			
S5904	001	0		29	10	S5904_001_0	5	4	Non-Preferred Brand	1	3	100000		2	100010110110101000000001				31		90	31		90	1	31		90							31				31	14										90.00		270.00						95.00		285.00						90.00		270.00																		95.00								90.00				
S5904	001	0		29	10	S5904_001_0	5	3	Preferred Brand	1	3	000001		2	100010110110101000000001				31		90	31		90	1	31		90							31				31	14										32.00		96.00						37.00		111.00						32.00		96.00																		37.00								32.00				
S5904	001	0		29	10	S5904_001_0	5	2	Non-Preferred Generic	1	3	000100		2	000010110110101000000110				31		90	31		90	1	31		90							31		31	14												16.00		48.00						21.00		63.00						8.00		24.00																		21.00					16.00							
S5904	001	0		29	10	S5904_001_0	5	1	Preferred Generic	1	3	001000		2	000010110110101000000110				31		90	31		90	1	31		90							31		31	14												6.00		18.00						10.00		30.00						0.00		0.00																		10.00					6.00							
S5904	001	0		29	10	S5904_001_0	5	5	Specialty Tier	1	3	100101		1	100010110110101000000111				31		90	31		90	1	31		90							31		31	14	31	14													1602.51	33		33					1602.51	33		33					33		33																	33				33			33			
S5904	002	0		29	10	S5904_002_0	4	2	Non-Preferred Generic	3	4	000100	1	2	000010110110101000000110				31		90	31		90	1	31		90							31		31	14												6.00		18.00						13.00		39.00						5.00		15.00																		13.00					6.00					1		
S5904	002	0		29	10	S5904_002_0	4	5	Specialty Tier	3	4	100101	1	1	100010110110101000000111				31		90	31		90	1	31		90							31		31	14	31	14													1602.51	33		33					1602.51	33		33					33		33																	33				33			33	2	2	
S5904	002	0		29	10	S5904_002_0	4	1	Preferred Generic	3	4	001000	1	2	000010110110101000000110				31		90	31		90	1	31		90							31		31	14												2.00		6.00						9.00		27.00						0.00		0.00																		9.00					2.00					1		
S5904	002	0		29	10	S5904_002_0	4	5	Specialty Tier	1	4	100101	1	1	100010110110101000000111				31		90	31		90	1	31		90							31		31	14	31	14													1602.51	33		33					1602.51	33		33					33		33																	33				33			33			
S5904	002	0		29	10	S5904_002_0	4	4	Non-Preferred Brand	1	4	100000	1	2	100010110110101000000001				31		90	31		90	1	31		90							31				31	14										85.00		255.00						94.00		282.00						85.00		255.00																		94.00								85.00				
S5904	002	0		29	10	S5904_002_0	4	3	Preferred Brand	1	4	000001	1	2	100010110110101000000001				31		90	31		90	1	31		90							31				31	14										35.00		105.00						42.00		126.00						35.00		105.00																		42.00								35.00				
S5904	002	0		29	10	S5904_002_0	4	1	Preferred Generic	1	4	001000	1	2	000010110110101000000110				31		90	31		90	1	31		90							31		31	14												2.00		6.00						9.00		27.00						0.00		0.00																		9.00					2.00							
S5904	002	0		29	10	S5904_002_0	4	2	Non-Preferred Generic	1	4	000100	1	2	000010110110101000000110				31		90	31		90	1	31		90							31		31	14												6.00		18.00						13.00		39.00						5.00		15.00																		13.00					6.00							
S5907	001	0		29	10	S5907_001_0	6	4	Specialty Tier	1	2	010010		1	110100000010001000000101	30		90							2			90							30		31		31	14					563.73	25		25																							25																	25				25			25			
S5907	001	0		29	10	S5907_001_0	6	3	Non-Preferred Brand	1	2	110000		3	110100000010001000000101	30		90							2			90							30		31		31	14		45.00		135.00	45.85	25		25																				135.00			25															45.00		25			45.00	25		45.00	25			
S5907	001	0		29	10	S5907_001_0	6	2	Preferred Brand	1	2	010001		2	110100000010001000000101	30		90							2			90							30		31		31	14		25.00		75.00																								75.00																		25.00					25.00			25.00				
S5907	001	0		29	10	S5907_001_0	6	1	Generic	1	2	010010		2	110100000010001000000101	30		90							2			90							30		31		31	14		6.00		18.00																								18.00																		6.00					6.00			6.00				
S5907	002	0		29	10	S5907_002_0	7	4	Specialty Tier	1	4	010010	1	1	110100000010001000000101	30		90							2			90							30		31		31	14					824.37	25		25																							25																	25				25			25			
S5907	002	0		29	10	S5907_002_0	7	3	Non-Preferred Brand	1	4	110000	1	3	110100000010001000000101	30		90							2			90							30		31		31	14		40.00		120.00	45.17	25		25																				120.00			25															40.00		25			40.00	25		40.00	25			
S5907	002	0		29	10	S5907_002_0	7	2	Preferred Brand	1	4	010001	1	2	110100000010001000000101	30		90							2			90							30		31		31	14		40.00		120.00																								120.00																		40.00					40.00			40.00				
S5907	002	0		29	10	S5907_002_0	7	1	Generic	3	4	010010	1	2	110100000010001000000101	30		90							2			90							30		31		31	14		7.00		21.00																								21.00																		7.00					7.00			7.00		1		
S5907	002	0		29	10	S5907_002_0	7	1	Generic	1	4	010010	1	2	110100000010001000000101	30		90							2			90							30		31		31	14		7.00		21.00																								21.00																		7.00					7.00			7.00				
S5916	001	0		29	10	S5916_001_0	6	5	Specialty Tier	1	3	101101		1	110000000010100000000101	30										30									30		31		31	14					420.00	28																							28																			28				28			28			
S5916	001	0		29	10	S5916_001_0	6	4	Non-Preferred Brand	1	3	100000		2	110100000010101000000001	30		90							1	30		90							30				31	14	2.83	85.00		255.00																					2.83	85.00		212.50																		85.00							2.74	85.00				
S5916	001	0		29	10	S5916_001_0	6	3	Preferred Brand	1	3	000001		2	110100000010101000000001	30		90							1	30		90							30				31	14	1.33	40.00		120.00																					1.33	40.00		100.00																		40.00							1.29	40.00				
S5916	001	0		29	10	S5916_001_0	6	2	Non-Preferred Generic	1	3	000100		2	010100000010101000000100	30		90							1	30		90							30		31				1.10	33.00		99.00																					1.10	33.00		66.00																		33.00				1.06	33.00							
S5916	001	0		29	10	S5916_001_0	6	1	Preferred Generic	1	3	001000		2	010100000010101000000100	30		90							1	30		90							30		31				0.25	7.50		22.50																					0.25	7.50		15.00																		7.50				0.24	7.50							
S5916	001	0		29	10	S5916_001_0	6	6	Injectable Drugs	1	3	101101		1	110000000010100000000101	30										30									30		31		31	14					53.00	28																							28																			28				28			28			
S5916	002	0		29	10	S5916_002_0	6	1	Preferred Generic	3	4	001000	1	2	010100000010101000000100	30		90							1	30		90							30		31				0.16	5.00		15.00																					0.16	5.00		10.00																		5.00				0.16	5.00					1		
S5916	002	0		29	10	S5916_002_0	6	6	Injectable Drugs	1	4	101101	1	1	110000000010100000000101	30										30									30		31		31	14					65.00	33																							33																			33				33			33			
S5916	002	0		29	10	S5916_002_0	6	5	Specialty Tier	1	4	101101	1	1	110000000010100000000101	30										30									30		31		31	14					439.00	33																							33																			33				33			33			
S5916	002	0		29	10	S5916_002_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	30		90							1	30		90							30				31	14	2.83	85.00		255.00																					2.83	85.00		212.50																		85.00							2.74	85.00				
S5916	002	0		29	10	S5916_002_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	30		90							1	30		90							30				31	14	1.33	40.00		120.00																					1.33	40.00		100.00																		40.00							1.29	40.00				
S5916	002	0		29	10	S5916_002_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000100	30		90							1	30		90							30		31				1.10	33.00		99.00																					1.10	33.00		66.00																		33.00				1.06	33.00							
S5916	002	0		29	10	S5916_002_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010101000000100	30		90							1	30		90							30		31				0.16	5.00		15.00																					0.16	5.00		10.00																		5.00				0.16	5.00							
S5921	003	0		29	10	S5921_003_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5921	003	0		29	10	S5921_003_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00				
S5921	003	0		29	10	S5921_003_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													603.00	33		33					603.00	33		33														33							33			33				33			33			
S5921	003	0		29	10	S5921_003_0	6	1	Preferred Generic	3	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															2.00							12.00				4.00					4.00					1		
S5921	003	0		29	10	S5921_003_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00							
S5921	003	0		29	10	S5921_003_0	6	3	Preferred Brand	3	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00		2	1	
S5921	003	0		29	10	S5921_003_0	6	4	Non-Preferred Brand	3	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00		2	1	
S5921	003	0		29	10	S5921_003_0	6	5	Specialty Tier	3	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													654.00	33		33					654.00	33		33														33							33			33				33			33	2	1	
S5921	003	0		29	10	S5921_003_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	003	0		29	10	S5921_003_0	6	2	Non-Preferred Generic	3	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00					1		
S5921	013	0		29	10	S5921_013_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	013	0		29	10	S5921_013_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00							
S5921	013	0		29	10	S5921_013_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5921	013	0		29	10	S5921_013_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00				
S5921	013	0		29	10	S5921_013_0	6	5	Specialty Tier	3	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													654.00	33		33					654.00	33		33														33							33			33				33			33	2	1	
S5921	013	0		29	10	S5921_013_0	6	1	Preferred Generic	3	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															2.00							12.00				4.00					4.00					1		
S5921	013	0		29	10	S5921_013_0	6	2	Non-Preferred Generic	3	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00					1		
S5921	013	0		29	10	S5921_013_0	6	3	Preferred Brand	3	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00		2	1	
S5921	013	0		29	10	S5921_013_0	6	4	Non-Preferred Brand	3	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00		2	1	
S5921	013	0		29	10	S5921_013_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													707.00	33		33					707.00	33		33														33							33			33				33			33			
S5921	023	0		29	10	S5921_023_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	023	0		29	10	S5921_023_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00							
S5921	023	0		29	10	S5921_023_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5921	023	0		29	10	S5921_023_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00				
S5921	023	0		29	10	S5921_023_0	6	5	Specialty Tier	3	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													654.00	33		33					654.00	33		33														33							33			33				33			33	2	1	
S5921	023	0		29	10	S5921_023_0	6	1	Preferred Generic	3	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															2.00							12.00				4.00					4.00					1		
S5921	023	0		29	10	S5921_023_0	6	2	Non-Preferred Generic	3	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00					1		
S5921	023	0		29	10	S5921_023_0	6	3	Preferred Brand	3	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00		2	1	
S5921	023	0		29	10	S5921_023_0	6	4	Non-Preferred Brand	3	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00		2	1	
S5921	023	0		29	10	S5921_023_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													575.00	33		33					575.00	33		33														33							33			33				33			33			
S5921	033	0		29	10	S5921_033_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00							
S5921	033	0		29	10	S5921_033_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5921	033	0		29	10	S5921_033_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00				
S5921	033	0		29	10	S5921_033_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													727.00	33		33					727.00	33		33														33							33			33				33			33			
S5921	033	0		29	10	S5921_033_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	033	0		29	10	S5921_033_0	6	2	Non-Preferred Generic	3	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00					1		
S5921	033	0		29	10	S5921_033_0	6	3	Preferred Brand	3	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00		2	1	
S5921	033	0		29	10	S5921_033_0	6	4	Non-Preferred Brand	3	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00		2	1	
S5921	033	0		29	10	S5921_033_0	6	5	Specialty Tier	3	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													654.00	33		33					654.00	33		33														33							33			33				33			33	2	1	
S5921	033	0		29	10	S5921_033_0	6	1	Preferred Generic	3	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															2.00							12.00				4.00					4.00					1		
S5921	043	0		29	10	S5921_043_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	043	0		29	10	S5921_043_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00							
S5921	043	0		29	10	S5921_043_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										33.00		99.00						45.00		135.00															84.00							135.00				45.00					45.00			45.00				
S5921	043	0		29	10	S5921_043_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										65.00		195.00						95.00		285.00															180.00							285.00				95.00					95.00			95.00				
S5921	043	0		29	10	S5921_043_0	6	5	Specialty Tier	3	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													654.00	33		33					654.00	33		33														33							33			33				33			33	2	1	
S5921	043	0		29	10	S5921_043_0	6	1	Preferred Generic	3	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															2.00							12.00				4.00					4.00					1		
S5921	043	0		29	10	S5921_043_0	6	2	Non-Preferred Generic	3	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00					1		
S5921	043	0		29	10	S5921_043_0	6	3	Preferred Brand	3	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										33.00		99.00						45.00		135.00															84.00							135.00				45.00					45.00			45.00		2	1	
S5921	043	0		29	10	S5921_043_0	6	4	Non-Preferred Brand	3	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										65.00		195.00						95.00		285.00															180.00							285.00				95.00					95.00			95.00		2	1	
S5921	043	0		29	10	S5921_043_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													710.00	33		33					710.00	33		33														33							33			33				33			33			
S5921	053	0		29	10	S5921_053_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	053	0		29	10	S5921_053_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00							
S5921	053	0		29	10	S5921_053_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5921	053	0		29	10	S5921_053_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00				
S5921	053	0		29	10	S5921_053_0	6	4	Non-Preferred Brand	3	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00		2	1	
S5921	053	0		29	10	S5921_053_0	6	1	Preferred Generic	3	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															2.00							12.00				4.00					4.00					1		
S5921	053	0		29	10	S5921_053_0	6	2	Non-Preferred Generic	3	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00					1		
S5921	053	0		29	10	S5921_053_0	6	3	Preferred Brand	3	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00		2	1	
S5921	053	0		29	10	S5921_053_0	6	5	Specialty Tier	3	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													654.00	33		33					654.00	33		33														33							33			33				33			33	2	1	
S5921	053	0		29	10	S5921_053_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													599.00	33		33					599.00	33		33														33							33			33				33			33			
S5921	063	0		29	10	S5921_063_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	063	0		29	10	S5921_063_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00							
S5921	063	0		29	10	S5921_063_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5921	063	0		29	10	S5921_063_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00				
S5921	063	0		29	10	S5921_063_0	6	5	Specialty Tier	3	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													654.00	33		33					654.00	33		33														33							33			33				33			33	2	1	
S5921	063	0		29	10	S5921_063_0	6	1	Preferred Generic	3	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															2.00							12.00				4.00					4.00					1		
S5921	063	0		29	10	S5921_063_0	6	2	Non-Preferred Generic	3	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00					1		
S5921	063	0		29	10	S5921_063_0	6	3	Preferred Brand	3	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00		2	1	
S5921	063	0		29	10	S5921_063_0	6	4	Non-Preferred Brand	3	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00		2	1	
S5921	063	0		29	10	S5921_063_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													574.00	33		33					574.00	33		33														33							33			33				33			33			
S5921	073	0		29	10	S5921_073_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													568.00	33		33					568.00	33		33														33							33			33				33			33			
S5921	073	0		29	10	S5921_073_0	6	1	Preferred Generic	3	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															2.00							12.00				4.00					4.00					1		
S5921	073	0		29	10	S5921_073_0	6	2	Non-Preferred Generic	3	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00					1		
S5921	073	0		29	10	S5921_073_0	6	3	Preferred Brand	3	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00		2	1	
S5921	073	0		29	10	S5921_073_0	6	4	Non-Preferred Brand	3	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00		2	1	
S5921	073	0		29	10	S5921_073_0	6	5	Specialty Tier	3	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													654.00	33		33					654.00	33		33														33							33			33				33			33	2	1	
S5921	073	0		29	10	S5921_073_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	073	0		29	10	S5921_073_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00							
S5921	073	0		29	10	S5921_073_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5921	073	0		29	10	S5921_073_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00				
S5921	083	0		29	10	S5921_083_0	6	2	Non-Preferred Generic	3	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00					1		
S5921	083	0		29	10	S5921_083_0	6	1	Preferred Generic	3	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															2.00							12.00				4.00					4.00					1		
S5921	083	0		29	10	S5921_083_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													490.00	33		33					490.00	33		33														33							33			33				33			33			
S5921	083	0		29	10	S5921_083_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00				
S5921	083	0		29	10	S5921_083_0	6	3	Preferred Brand	3	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00		2	1	
S5921	083	0		29	10	S5921_083_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00							
S5921	083	0		29	10	S5921_083_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	083	0		29	10	S5921_083_0	6	5	Specialty Tier	3	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													654.00	33		33					654.00	33		33														33							33			33				33			33	2	1	
S5921	083	0		29	10	S5921_083_0	6	4	Non-Preferred Brand	3	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00		2	1	
S5921	083	0		29	10	S5921_083_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5921	093	0		29	10	S5921_093_0	6	5	Specialty Tier	3	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													654.00	33		33					654.00	33		33														33							33			33				33			33	2	1	
S5921	093	0		29	10	S5921_093_0	6	4	Non-Preferred Brand	3	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00		2	1	
S5921	093	0		29	10	S5921_093_0	6	3	Preferred Brand	3	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00		2	1	
S5921	093	0		29	10	S5921_093_0	6	2	Non-Preferred Generic	3	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00					1		
S5921	093	0		29	10	S5921_093_0	6	1	Preferred Generic	3	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															2.00							12.00				4.00					4.00					1		
S5921	093	0		29	10	S5921_093_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													636.00	33		33					636.00	33		33														33							33			33				33			33			
S5921	093	0		29	10	S5921_093_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00				
S5921	093	0		29	10	S5921_093_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5921	093	0		29	10	S5921_093_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	093	0		29	10	S5921_093_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00							
S5921	103	0		29	10	S5921_103_0	6	4	Non-Preferred Brand	3	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00		2	1	
S5921	103	0		29	10	S5921_103_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00							
S5921	103	0		29	10	S5921_103_0	6	2	Non-Preferred Generic	3	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00					1		
S5921	103	0		29	10	S5921_103_0	6	1	Preferred Generic	3	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															2.00							12.00				4.00					4.00					1		
S5921	103	0		29	10	S5921_103_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													632.00	33		33					632.00	33		33														33							33			33				33			33			
S5921	103	0		29	10	S5921_103_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00				
S5921	103	0		29	10	S5921_103_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5921	103	0		29	10	S5921_103_0	6	5	Specialty Tier	3	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													654.00	33		33					654.00	33		33														33							33			33				33			33	2	1	
S5921	103	0		29	10	S5921_103_0	6	3	Preferred Brand	3	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00		2	1	
S5921	103	0		29	10	S5921_103_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	113	0		29	10	S5921_113_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5921	113	0		29	10	S5921_113_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00				
S5921	113	0		29	10	S5921_113_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													480.00	33		33					480.00	33		33														33							33			33				33			33			
S5921	113	0		29	10	S5921_113_0	6	1	Preferred Generic	3	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															2.00							12.00				4.00					4.00					1		
S5921	113	0		29	10	S5921_113_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	113	0		29	10	S5921_113_0	6	3	Preferred Brand	3	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00		2	1	
S5921	113	0		29	10	S5921_113_0	6	4	Non-Preferred Brand	3	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00		2	1	
S5921	113	0		29	10	S5921_113_0	6	5	Specialty Tier	3	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													654.00	33		33					654.00	33		33														33							33			33				33			33	2	1	
S5921	113	0		29	10	S5921_113_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00							
S5921	113	0		29	10	S5921_113_0	6	2	Non-Preferred Generic	3	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00					1		
S5921	123	0		29	10	S5921_123_0	6	3	Preferred Brand	3	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00		2	1	
S5921	123	0		29	10	S5921_123_0	6	2	Non-Preferred Generic	3	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00					1		
S5921	123	0		29	10	S5921_123_0	6	1	Preferred Generic	3	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															2.00							12.00				4.00					4.00					1		
S5921	123	0		29	10	S5921_123_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													582.00	33		33					582.00	33		33														33							33			33				33			33			
S5921	123	0		29	10	S5921_123_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00				
S5921	123	0		29	10	S5921_123_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5921	123	0		29	10	S5921_123_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	123	0		29	10	S5921_123_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00							
S5921	123	0		29	10	S5921_123_0	6	5	Specialty Tier	3	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													654.00	33		33					654.00	33		33														33							33			33				33			33	2	1	
S5921	123	0		29	10	S5921_123_0	6	4	Non-Preferred Brand	3	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00		2	1	
S5921	133	0		29	10	S5921_133_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	133	0		29	10	S5921_133_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00							
S5921	133	0		29	10	S5921_133_0	6	5	Specialty Tier	3	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													654.00	33		33					654.00	33		33														33							33			33				33			33	2	1	
S5921	133	0		29	10	S5921_133_0	6	4	Non-Preferred Brand	3	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00		2	1	
S5921	133	0		29	10	S5921_133_0	6	3	Preferred Brand	3	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00		2	1	
S5921	133	0		29	10	S5921_133_0	6	2	Non-Preferred Generic	3	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00					1		
S5921	133	0		29	10	S5921_133_0	6	1	Preferred Generic	3	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															2.00							12.00				4.00					4.00					1		
S5921	133	0		29	10	S5921_133_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													550.00	33		33					550.00	33		33														33							33			33				33			33			
S5921	133	0		29	10	S5921_133_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00				
S5921	133	0		29	10	S5921_133_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5921	143	0		29	10	S5921_143_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	143	0		29	10	S5921_143_0	6	3	Preferred Brand	3	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00		2	1	
S5921	143	0		29	10	S5921_143_0	6	4	Non-Preferred Brand	3	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00		2	1	
S5921	143	0		29	10	S5921_143_0	6	2	Non-Preferred Generic	3	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00					1		
S5921	143	0		29	10	S5921_143_0	6	5	Specialty Tier	3	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													654.00	33		33					654.00	33		33														33							33			33				33			33	2	1	
S5921	143	0		29	10	S5921_143_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													595.00	33		33					595.00	33		33														33							33			33				33			33			
S5921	143	0		29	10	S5921_143_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00				
S5921	143	0		29	10	S5921_143_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5921	143	0		29	10	S5921_143_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00							
S5921	143	0		29	10	S5921_143_0	6	1	Preferred Generic	3	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															2.00							12.00				4.00					4.00					1		
S5921	153	0		29	10	S5921_153_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5921	153	0		29	10	S5921_153_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00				
S5921	153	0		29	10	S5921_153_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													548.00	33		33					548.00	33		33														33							33			33				33			33			
S5921	153	0		29	10	S5921_153_0	6	1	Preferred Generic	3	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															2.00							12.00				4.00					4.00					1		
S5921	153	0		29	10	S5921_153_0	6	2	Non-Preferred Generic	3	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00					1		
S5921	153	0		29	10	S5921_153_0	6	3	Preferred Brand	3	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00		2	1	
S5921	153	0		29	10	S5921_153_0	6	4	Non-Preferred Brand	3	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00		2	1	
S5921	153	0		29	10	S5921_153_0	6	5	Specialty Tier	3	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													654.00	33		33					654.00	33		33														33							33			33				33			33	2	1	
S5921	153	0		29	10	S5921_153_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	153	0		29	10	S5921_153_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00							
S5921	163	0		29	10	S5921_163_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													521.00	33		33					521.00	33		33														33							33			33				33			33			
S5921	163	0		29	10	S5921_163_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00				
S5921	163	0		29	10	S5921_163_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5921	163	0		29	10	S5921_163_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00							
S5921	163	0		29	10	S5921_163_0	6	1	Preferred Generic	3	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															2.00							12.00				4.00					4.00					1		
S5921	163	0		29	10	S5921_163_0	6	5	Specialty Tier	3	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													654.00	33		33					654.00	33		33														33							33			33				33			33	2	1	
S5921	163	0		29	10	S5921_163_0	6	4	Non-Preferred Brand	3	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00		2	1	
S5921	163	0		29	10	S5921_163_0	6	3	Preferred Brand	3	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00		2	1	
S5921	163	0		29	10	S5921_163_0	6	2	Non-Preferred Generic	3	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00					1		
S5921	163	0		29	10	S5921_163_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	173	0		29	10	S5921_173_0	6	4	Non-Preferred Brand	3	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										65.00		195.00						95.00		285.00															180.00							285.00				95.00					95.00			95.00		2	1	
S5921	173	0		29	10	S5921_173_0	6	3	Preferred Brand	3	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										24.00		72.00						45.00		135.00															57.00							135.00				45.00					45.00			45.00		2	1	
S5921	173	0		29	10	S5921_173_0	6	2	Non-Preferred Generic	3	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00					1		
S5921	173	0		29	10	S5921_173_0	6	1	Preferred Generic	3	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															2.00							12.00				4.00					4.00					1		
S5921	173	0		29	10	S5921_173_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													527.00	33		33					527.00	33		33														33							33			33				33			33			
S5921	173	0		29	10	S5921_173_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										65.00		195.00						95.00		285.00															180.00							285.00				95.00					95.00			95.00				
S5921	173	0		29	10	S5921_173_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										24.00		72.00						45.00		135.00															57.00							135.00				45.00					45.00			45.00				
S5921	173	0		29	10	S5921_173_0	6	5	Specialty Tier	3	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													654.00	33		33					654.00	33		33														33							33			33				33			33	2	1	
S5921	173	0		29	10	S5921_173_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	173	0		29	10	S5921_173_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00							
S5921	183	0		29	10	S5921_183_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	183	0		29	10	S5921_183_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00							
S5921	183	0		29	10	S5921_183_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5921	183	0		29	10	S5921_183_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00				
S5921	183	0		29	10	S5921_183_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													605.00	33		33					605.00	33		33														33							33			33				33			33			
S5921	183	0		29	10	S5921_183_0	6	1	Preferred Generic	3	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															2.00							12.00				4.00					4.00					1		
S5921	183	0		29	10	S5921_183_0	6	2	Non-Preferred Generic	3	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00					1		
S5921	183	0		29	10	S5921_183_0	6	3	Preferred Brand	3	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00		2	1	
S5921	183	0		29	10	S5921_183_0	6	4	Non-Preferred Brand	3	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00		2	1	
S5921	183	0		29	10	S5921_183_0	6	5	Specialty Tier	3	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													654.00	33		33					654.00	33		33														33							33			33				33			33	2	1	
S5921	193	0		29	10	S5921_193_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00				
S5921	193	0		29	10	S5921_193_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													738.00	33		33					738.00	33		33														33							33			33				33			33			
S5921	193	0		29	10	S5921_193_0	6	1	Preferred Generic	3	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															2.00							12.00				4.00					4.00					1		
S5921	193	0		29	10	S5921_193_0	6	2	Non-Preferred Generic	3	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00					1		
S5921	193	0		29	10	S5921_193_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5921	193	0		29	10	S5921_193_0	6	4	Non-Preferred Brand	3	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00		2	1	
S5921	193	0		29	10	S5921_193_0	6	5	Specialty Tier	3	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													654.00	33		33					654.00	33		33														33							33			33				33			33	2	1	
S5921	193	0		29	10	S5921_193_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	193	0		29	10	S5921_193_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00							
S5921	193	0		29	10	S5921_193_0	6	3	Preferred Brand	3	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00		2	1	
S5921	213	0		29	10	S5921_213_0	6	5	Specialty Tier	3	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													654.00	33		33					654.00	33		33														33							33			33				33			33	2	1	
S5921	213	0		29	10	S5921_213_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	213	0		29	10	S5921_213_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00							
S5921	213	0		29	10	S5921_213_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										24.00		72.00						45.00		135.00															57.00							135.00				45.00					45.00			45.00				
S5921	213	0		29	10	S5921_213_0	6	4	Non-Preferred Brand	3	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										65.00		195.00						95.00		285.00															180.00							285.00				95.00					95.00			95.00		2	1	
S5921	213	0		29	10	S5921_213_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													641.00	33		33					641.00	33		33														33							33			33				33			33			
S5921	213	0		29	10	S5921_213_0	6	1	Preferred Generic	3	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															2.00							12.00				4.00					4.00					1		
S5921	213	0		29	10	S5921_213_0	6	2	Non-Preferred Generic	3	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00					1		
S5921	213	0		29	10	S5921_213_0	6	3	Preferred Brand	3	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										24.00		72.00						45.00		135.00															57.00							135.00				45.00					45.00			45.00		2	1	
S5921	213	0		29	10	S5921_213_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										65.00		195.00						95.00		285.00															180.00							285.00				95.00					95.00			95.00				
S5921	223	0		29	10	S5921_223_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	223	0		29	10	S5921_223_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													518.00	33		33					518.00	33		33														33							33			33				33			33			
S5921	223	0		29	10	S5921_223_0	6	5	Specialty Tier	3	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													654.00	33		33					654.00	33		33														33							33			33				33			33	2	1	
S5921	223	0		29	10	S5921_223_0	6	4	Non-Preferred Brand	3	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00		2	1	
S5921	223	0		29	10	S5921_223_0	6	3	Preferred Brand	3	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00		2	1	
S5921	223	0		29	10	S5921_223_0	6	2	Non-Preferred Generic	3	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00					1		
S5921	223	0		29	10	S5921_223_0	6	1	Preferred Generic	3	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															2.00							12.00				4.00					4.00					1		
S5921	223	0		29	10	S5921_223_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00				
S5921	223	0		29	10	S5921_223_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5921	223	0		29	10	S5921_223_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00							
S5921	233	0		29	10	S5921_233_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	233	0		29	10	S5921_233_0	6	5	Specialty Tier	3	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													654.00	33		33					654.00	33		33														33							33			33				33			33	2	1	
S5921	233	0		29	10	S5921_233_0	6	4	Non-Preferred Brand	3	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										65.00		195.00						95.00		285.00															180.00							285.00				95.00					95.00			95.00		2	1	
S5921	233	0		29	10	S5921_233_0	6	3	Preferred Brand	3	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										31.00		93.00						45.00		135.00															78.00							135.00				45.00					45.00			45.00		2	1	
S5921	233	0		29	10	S5921_233_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00							
S5921	233	0		29	10	S5921_233_0	6	1	Preferred Generic	3	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															2.00							12.00				4.00					4.00					1		
S5921	233	0		29	10	S5921_233_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													547.00	33		33					547.00	33		33														33							33			33				33			33			
S5921	233	0		29	10	S5921_233_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										65.00		195.00						95.00		285.00															180.00							285.00				95.00					95.00			95.00				
S5921	233	0		29	10	S5921_233_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										31.00		93.00						45.00		135.00															78.00							135.00				45.00					45.00			45.00				
S5921	233	0		29	10	S5921_233_0	6	2	Non-Preferred Generic	3	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00					1		
S5921	235	0		29	10	S5921_235_0	6	5	Specialty Tier	3	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													654.00	33		33					654.00	33		33														33							33			33				33			33	2	1	
S5921	235	0		29	10	S5921_235_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00							
S5921	235	0		29	10	S5921_235_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	235	0		29	10	S5921_235_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5921	235	0		29	10	S5921_235_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00				
S5921	235	0		29	10	S5921_235_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													538.00	33		33					538.00	33		33														33							33			33				33			33			
S5921	235	0		29	10	S5921_235_0	6	1	Preferred Generic	3	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															2.00							12.00				4.00					4.00					1		
S5921	235	0		29	10	S5921_235_0	6	2	Non-Preferred Generic	3	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00					1		
S5921	235	0		29	10	S5921_235_0	6	3	Preferred Brand	3	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00		2	1	
S5921	235	0		29	10	S5921_235_0	6	4	Non-Preferred Brand	3	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00		2	1	
S5921	239	0		29	10	S5921_239_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	239	0		29	10	S5921_239_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00							
S5921	239	0		29	10	S5921_239_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5921	239	0		29	10	S5921_239_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00				
S5921	239	0		29	10	S5921_239_0	6	4	Non-Preferred Brand	3	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00		2	1	
S5921	239	0		29	10	S5921_239_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													638.00	33		33					638.00	33		33														33							33			33				33			33			
S5921	239	0		29	10	S5921_239_0	6	1	Preferred Generic	3	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															2.00							12.00				4.00					4.00					1		
S5921	239	0		29	10	S5921_239_0	6	2	Non-Preferred Generic	3	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00					1		
S5921	239	0		29	10	S5921_239_0	6	3	Preferred Brand	3	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00		2	1	
S5921	239	0		29	10	S5921_239_0	6	5	Specialty Tier	3	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													654.00	33		33					654.00	33		33														33							33			33				33			33	2	1	
S5921	249	0		29	10	S5921_249_0	6	3	Preferred Brand	3	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00		2	1	
S5921	249	0		29	10	S5921_249_0	6	4	Non-Preferred Brand	3	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00		2	1	
S5921	249	0		29	10	S5921_249_0	6	5	Specialty Tier	3	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													654.00	33		33					654.00	33		33														33							33			33				33			33	2	1	
S5921	249	0		29	10	S5921_249_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	249	0		29	10	S5921_249_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00							
S5921	249	0		29	10	S5921_249_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5921	249	0		29	10	S5921_249_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00				
S5921	249	0		29	10	S5921_249_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													556.00	33		33					556.00	33		33														33							33			33				33			33			
S5921	249	0		29	10	S5921_249_0	6	1	Preferred Generic	3	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															2.00							12.00				4.00					4.00					1		
S5921	249	0		29	10	S5921_249_0	6	2	Non-Preferred Generic	3	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00					1		
S5921	263	0		29	10	S5921_263_0	6	4	Non-Preferred Brand	3	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00		2	1	
S5921	263	0		29	10	S5921_263_0	6	3	Preferred Brand	3	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00		2	1	
S5921	263	0		29	10	S5921_263_0	6	5	Specialty Tier	3	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													654.00	33		33					654.00	33		33														33							33			33				33			33	2	1	
S5921	263	0		29	10	S5921_263_0	6	2	Non-Preferred Generic	3	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00					1		
S5921	263	0		29	10	S5921_263_0	6	1	Preferred Generic	3	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															2.00							12.00				4.00					4.00					1		
S5921	263	0		29	10	S5921_263_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													630.00	33		33					630.00	33		33														33							33			33				33			33			
S5921	263	0		29	10	S5921_263_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00				
S5921	263	0		29	10	S5921_263_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5921	263	0		29	10	S5921_263_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00							
S5921	263	0		29	10	S5921_263_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	273	0		29	10	S5921_273_0	6	2	Non-Preferred Generic	3	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00					1		
S5921	273	0		29	10	S5921_273_0	6	1	Preferred Generic	3	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															2.00							12.00				4.00					4.00					1		
S5921	273	0		29	10	S5921_273_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													577.00	33		33					577.00	33		33														33							33			33				33			33			
S5921	273	0		29	10	S5921_273_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00				
S5921	273	0		29	10	S5921_273_0	6	3	Preferred Brand	3	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00		2	1	
S5921	273	0		29	10	S5921_273_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00							
S5921	273	0		29	10	S5921_273_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	273	0		29	10	S5921_273_0	6	5	Specialty Tier	3	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													654.00	33		33					654.00	33		33														33							33			33				33			33	2	1	
S5921	273	0		29	10	S5921_273_0	6	4	Non-Preferred Brand	3	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00		2	1	
S5921	273	0		29	10	S5921_273_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5921	293	0		29	10	S5921_293_0	6	2	Non-Preferred Generic	3	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00					1		
S5921	293	0		29	10	S5921_293_0	6	3	Preferred Brand	3	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00		2	1	
S5921	293	0		29	10	S5921_293_0	6	4	Non-Preferred Brand	3	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00		2	1	
S5921	293	0		29	10	S5921_293_0	6	5	Specialty Tier	3	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													654.00	33		33					654.00	33		33														33							33			33				33			33	2	1	
S5921	293	0		29	10	S5921_293_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	293	0		29	10	S5921_293_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00							
S5921	293	0		29	10	S5921_293_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5921	293	0		29	10	S5921_293_0	6	1	Preferred Generic	3	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															2.00							12.00				4.00					4.00					1		
S5921	293	0		29	10	S5921_293_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00				
S5921	293	0		29	10	S5921_293_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													554.00	33		33					554.00	33		33														33							33			33				33			33			
S5921	303	0		29	10	S5921_303_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	303	0		29	10	S5921_303_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00							
S5921	303	0		29	10	S5921_303_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5921	303	0		29	10	S5921_303_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00				
S5921	303	0		29	10	S5921_303_0	6	5	Specialty Tier	3	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													654.00	33		33					654.00	33		33														33							33			33				33			33	2	1	
S5921	303	0		29	10	S5921_303_0	6	1	Preferred Generic	3	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															2.00							12.00				4.00					4.00					1		
S5921	303	0		29	10	S5921_303_0	6	2	Non-Preferred Generic	3	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00					1		
S5921	303	0		29	10	S5921_303_0	6	3	Preferred Brand	3	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00		2	1	
S5921	303	0		29	10	S5921_303_0	6	4	Non-Preferred Brand	3	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00		2	1	
S5921	303	0		29	10	S5921_303_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													586.00	33		33					586.00	33		33														33							33			33				33			33			
S5921	323	0		29	10	S5921_323_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00							
S5921	323	0		29	10	S5921_323_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5921	323	0		29	10	S5921_323_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00				
S5921	323	0		29	10	S5921_323_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													554.00	33		33					554.00	33		33														33							33			33				33			33			
S5921	323	0		29	10	S5921_323_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	323	0		29	10	S5921_323_0	6	2	Non-Preferred Generic	3	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00					1		
S5921	323	0		29	10	S5921_323_0	6	3	Preferred Brand	3	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00		2	1	
S5921	323	0		29	10	S5921_323_0	6	4	Non-Preferred Brand	3	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00		2	1	
S5921	323	0		29	10	S5921_323_0	6	5	Specialty Tier	3	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													654.00	33		33					654.00	33		33														33							33			33				33			33	2	1	
S5921	323	0		29	10	S5921_323_0	6	1	Preferred Generic	3	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															2.00							12.00				4.00					4.00					1		
S5921	333	0		29	10	S5921_333_0	6	1	Preferred Generic	1	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	333	0		29	10	S5921_333_0	6	2	Non-Preferred Generic	1	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00							
S5921	333	0		29	10	S5921_333_0	6	3	Preferred Brand	1	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00				
S5921	333	0		29	10	S5921_333_0	6	4	Non-Preferred Brand	1	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00				
S5921	333	0		29	10	S5921_333_0	6	5	Specialty Tier	3	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													654.00	33		33					654.00	33		33														33							33			33				33			33	2	1	
S5921	333	0		29	10	S5921_333_0	6	1	Preferred Generic	3	4	001000	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						4.00		12.00															2.00							12.00				4.00					4.00					1		
S5921	333	0		29	10	S5921_333_0	6	2	Non-Preferred Generic	3	4	000100	1	2	000010110110000001001100				31		90	31		90	1						90			90	31		31													5.00		15.00						7.00		21.00															5.00							21.00				7.00					7.00					1		
S5921	333	0		29	10	S5921_333_0	6	3	Preferred Brand	3	4	010001	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										40.00		120.00						45.00		135.00															105.00							135.00				45.00					45.00			45.00		2	1	
S5921	333	0		29	10	S5921_333_0	6	4	Non-Preferred Brand	3	4	100100	1	2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										76.00		228.00						95.00		285.00															213.00							285.00				95.00					95.00			95.00		2	1	
S5921	333	0		29	10	S5921_333_0	6	5	Specialty Tier	1	4	010010	1	1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													472.00	33		33					472.00	33		33														33							33			33				33			33			
S5921	348	0		29	10	S5921_348_0	5	4	Non-Preferred Brand	1	2	100100		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										45.00		135.00						70.00		210.00															120.00							210.00				70.00					70.00			70.00				
S5921	348	0		29	10	S5921_348_0	5	3	Preferred Brand	1	2	010001		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										25.00		75.00						35.00		105.00															60.00							105.00				35.00					35.00			35.00				
S5921	348	0		29	10	S5921_348_0	5	2	Non-Preferred Generic	1	2	000100		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						5.00		15.00															2.00							15.00				5.00					5.00							
S5921	348	0		29	10	S5921_348_0	5	1	Preferred Generic	1	2	001000		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													1.00		3.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	348	0		29	10	S5921_348_0	5	5	Specialty Tier	1	2	010010		1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													379.00	25		25					379.00	25		25														25							25			25				25			25			
S5921	349	0		29	10	S5921_349_0	5	4	Non-Preferred Brand	1	2	100100		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										45.00		135.00						70.00		210.00															120.00							210.00				70.00					70.00			70.00				
S5921	349	0		29	10	S5921_349_0	5	3	Preferred Brand	1	2	010001		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										25.00		75.00						35.00		105.00															60.00							105.00				35.00					35.00			35.00				
S5921	349	0		29	10	S5921_349_0	5	2	Non-Preferred Generic	1	2	000100		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						5.00		15.00															2.00							15.00				5.00					5.00							
S5921	349	0		29	10	S5921_349_0	5	1	Preferred Generic	1	2	001000		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													1.00		3.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	349	0		29	10	S5921_349_0	5	5	Specialty Tier	1	2	010010		1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													379.00	25		25					379.00	25		25														25							25			25				25			25			
S5921	350	0		29	10	S5921_350_0	5	4	Non-Preferred Brand	1	2	100100		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										45.00		135.00						70.00		210.00															120.00							210.00				70.00					70.00			70.00				
S5921	350	0		29	10	S5921_350_0	5	5	Specialty Tier	1	2	010010		1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													379.00	25		25					379.00	25		25														25							25			25				25			25			
S5921	350	0		29	10	S5921_350_0	5	3	Preferred Brand	1	2	010001		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										25.00		75.00						35.00		105.00															60.00							105.00				35.00					35.00			35.00				
S5921	350	0		29	10	S5921_350_0	5	2	Non-Preferred Generic	1	2	000100		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						5.00		15.00															2.00							15.00				5.00					5.00							
S5921	350	0		29	10	S5921_350_0	5	1	Preferred Generic	1	2	001000		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													1.00		3.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	351	0		29	10	S5921_351_0	5	4	Non-Preferred Brand	1	2	100100		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										45.00		135.00						70.00		210.00															120.00							210.00				70.00					70.00			70.00				
S5921	351	0		29	10	S5921_351_0	5	2	Non-Preferred Generic	1	2	000100		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						5.00		15.00															2.00							15.00				5.00					5.00							
S5921	351	0		29	10	S5921_351_0	5	1	Preferred Generic	1	2	001000		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													1.00		3.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	351	0		29	10	S5921_351_0	5	3	Preferred Brand	1	2	010001		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										25.00		75.00						35.00		105.00															60.00							105.00				35.00					35.00			35.00				
S5921	351	0		29	10	S5921_351_0	5	5	Specialty Tier	1	2	010010		1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													379.00	25		25					379.00	25		25														25							25			25				25			25			
S5921	352	0		29	10	S5921_352_0	5	2	Non-Preferred Generic	1	2	000100		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						5.00		15.00															2.00							15.00				5.00					5.00							
S5921	352	0		29	10	S5921_352_0	5	1	Preferred Generic	1	2	001000		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													1.00		3.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	352	0		29	10	S5921_352_0	5	3	Preferred Brand	1	2	010001		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										25.00		75.00						35.00		105.00															60.00							105.00				35.00					35.00			35.00				
S5921	352	0		29	10	S5921_352_0	5	4	Non-Preferred Brand	1	2	100100		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										45.00		135.00						70.00		210.00															120.00							210.00				70.00					70.00			70.00				
S5921	352	0		29	10	S5921_352_0	5	5	Specialty Tier	1	2	010010		1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													379.00	25		25					379.00	25		25														25							25			25				25			25			
S5921	353	0		29	10	S5921_353_0	5	2	Non-Preferred Generic	1	2	000100		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						5.00		15.00															2.00							15.00				5.00					5.00							
S5921	353	0		29	10	S5921_353_0	5	3	Preferred Brand	1	2	010001		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										25.00		75.00						35.00		105.00															60.00							105.00				35.00					35.00			35.00				
S5921	353	0		29	10	S5921_353_0	5	4	Non-Preferred Brand	1	2	100100		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										45.00		135.00						70.00		210.00															120.00							210.00				70.00					70.00			70.00				
S5921	353	0		29	10	S5921_353_0	5	5	Specialty Tier	1	2	010010		1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													379.00	25		25					379.00	25		25														25							25			25				25			25			
S5921	353	0		29	10	S5921_353_0	5	1	Preferred Generic	1	2	001000		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													1.00		3.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	354	0		29	10	S5921_354_0	5	1	Preferred Generic	1	2	001000		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													1.00		3.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	354	0		29	10	S5921_354_0	5	3	Preferred Brand	1	2	010001		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										25.00		75.00						35.00		105.00															60.00							105.00				35.00					35.00			35.00				
S5921	354	0		29	10	S5921_354_0	5	4	Non-Preferred Brand	1	2	100100		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										45.00		135.00						70.00		210.00															120.00							210.00				70.00					70.00			70.00				
S5921	354	0		29	10	S5921_354_0	5	5	Specialty Tier	1	2	010010		1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													379.00	25		25					379.00	25		25														25							25			25				25			25			
S5921	354	0		29	10	S5921_354_0	5	2	Non-Preferred Generic	1	2	000100		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						5.00		15.00															2.00							15.00				5.00					5.00							
S5921	355	0		29	10	S5921_355_0	5	3	Preferred Brand	1	2	010001		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										25.00		75.00						35.00		105.00															60.00							105.00				35.00					35.00			35.00				
S5921	355	0		29	10	S5921_355_0	5	4	Non-Preferred Brand	1	2	100100		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										45.00		135.00						70.00		210.00															120.00							210.00				70.00					70.00			70.00				
S5921	355	0		29	10	S5921_355_0	5	5	Specialty Tier	1	2	010010		1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													379.00	25		25					379.00	25		25														25							25			25				25			25			
S5921	355	0		29	10	S5921_355_0	5	2	Non-Preferred Generic	1	2	000100		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						5.00		15.00															2.00							15.00				5.00					5.00							
S5921	355	0		29	10	S5921_355_0	5	1	Preferred Generic	1	2	001000		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													1.00		3.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	356	0		29	10	S5921_356_0	5	4	Non-Preferred Brand	1	2	100100		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										45.00		135.00						70.00		210.00															120.00							210.00				70.00					70.00			70.00				
S5921	356	0		29	10	S5921_356_0	5	1	Preferred Generic	1	2	001000		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													1.00		3.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	356	0		29	10	S5921_356_0	5	5	Specialty Tier	1	2	010010		1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													379.00	25		25					379.00	25		25														25							25			25				25			25			
S5921	356	0		29	10	S5921_356_0	5	2	Non-Preferred Generic	1	2	000100		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						5.00		15.00															2.00							15.00				5.00					5.00							
S5921	356	0		29	10	S5921_356_0	5	3	Preferred Brand	1	2	010001		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										25.00		75.00						35.00		105.00															60.00							105.00				35.00					35.00			35.00				
S5921	357	0		29	10	S5921_357_0	5	5	Specialty Tier	1	2	010010		1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													379.00	25		25					379.00	25		25														25							25			25				25			25			
S5921	357	0		29	10	S5921_357_0	5	4	Non-Preferred Brand	1	2	100100		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										45.00		135.00						70.00		210.00															120.00							210.00				70.00					70.00			70.00				
S5921	357	0		29	10	S5921_357_0	5	1	Preferred Generic	1	2	001000		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													1.00		3.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	357	0		29	10	S5921_357_0	5	2	Non-Preferred Generic	1	2	000100		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						5.00		15.00															2.00							15.00				5.00					5.00							
S5921	357	0		29	10	S5921_357_0	5	3	Preferred Brand	1	2	010001		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										25.00		75.00						35.00		105.00															60.00							105.00				35.00					35.00			35.00				
S5921	358	0		29	10	S5921_358_0	5	1	Preferred Generic	1	2	001000		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													1.00		3.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	358	0		29	10	S5921_358_0	5	4	Non-Preferred Brand	1	2	100100		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										45.00		135.00						70.00		210.00															120.00							210.00				70.00					70.00			70.00				
S5921	358	0		29	10	S5921_358_0	5	5	Specialty Tier	1	2	010010		1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													379.00	25		25					379.00	25		25														25							25			25				25			25			
S5921	358	0		29	10	S5921_358_0	5	2	Non-Preferred Generic	1	2	000100		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						5.00		15.00															2.00							15.00				5.00					5.00							
S5921	358	0		29	10	S5921_358_0	5	3	Preferred Brand	1	2	010001		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										25.00		75.00						35.00		105.00															60.00							105.00				35.00					35.00			35.00				
S5921	359	0		29	10	S5921_359_0	5	4	Non-Preferred Brand	1	2	100100		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										45.00		135.00						70.00		210.00															120.00							210.00				70.00					70.00			70.00				
S5921	359	0		29	10	S5921_359_0	5	5	Specialty Tier	1	2	010010		1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													379.00	25		25					379.00	25		25														25							25			25				25			25			
S5921	359	0		29	10	S5921_359_0	5	3	Preferred Brand	1	2	010001		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										25.00		75.00						35.00		105.00															60.00							105.00				35.00					35.00			35.00				
S5921	359	0		29	10	S5921_359_0	5	2	Non-Preferred Generic	1	2	000100		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						5.00		15.00															2.00							15.00				5.00					5.00							
S5921	359	0		29	10	S5921_359_0	5	1	Preferred Generic	1	2	001000		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													1.00		3.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	360	0		29	10	S5921_360_0	5	1	Preferred Generic	1	2	001000		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													1.00		3.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	360	0		29	10	S5921_360_0	5	2	Non-Preferred Generic	1	2	000100		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						5.00		15.00															2.00							15.00				5.00					5.00							
S5921	360	0		29	10	S5921_360_0	5	3	Preferred Brand	1	2	010001		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										25.00		75.00						35.00		105.00															60.00							105.00				35.00					35.00			35.00				
S5921	360	0		29	10	S5921_360_0	5	4	Non-Preferred Brand	1	2	100100		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										45.00		135.00						70.00		210.00															120.00							210.00				70.00					70.00			70.00				
S5921	360	0		29	10	S5921_360_0	5	5	Specialty Tier	1	2	010010		1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													379.00	25		25					379.00	25		25														25							25			25				25			25			
S5921	361	0		29	10	S5921_361_0	5	5	Specialty Tier	1	2	010010		1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													379.00	25		25					379.00	25		25														25							25			25				25			25			
S5921	361	0		29	10	S5921_361_0	5	4	Non-Preferred Brand	1	2	100100		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										45.00		135.00						70.00		210.00															120.00							210.00				70.00					70.00			70.00				
S5921	361	0		29	10	S5921_361_0	5	3	Preferred Brand	1	2	010001		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										25.00		75.00						35.00		105.00															60.00							105.00				35.00					35.00			35.00				
S5921	361	0		29	10	S5921_361_0	5	1	Preferred Generic	1	2	001000		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													1.00		3.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	361	0		29	10	S5921_361_0	5	2	Non-Preferred Generic	1	2	000100		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						5.00		15.00															2.00							15.00				5.00					5.00							
S5921	362	0		29	10	S5921_362_0	5	4	Non-Preferred Brand	1	2	100100		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										45.00		135.00						70.00		210.00															120.00							210.00				70.00					70.00			70.00				
S5921	362	0		29	10	S5921_362_0	5	3	Preferred Brand	1	2	010001		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										25.00		75.00						35.00		105.00															60.00							105.00				35.00					35.00			35.00				
S5921	362	0		29	10	S5921_362_0	5	2	Non-Preferred Generic	1	2	000100		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						5.00		15.00															2.00							15.00				5.00					5.00							
S5921	362	0		29	10	S5921_362_0	5	1	Preferred Generic	1	2	001000		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													1.00		3.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	362	0		29	10	S5921_362_0	5	5	Specialty Tier	1	2	010010		1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													379.00	25		25					379.00	25		25														25							25			25				25			25			
S5921	363	0		29	10	S5921_363_0	5	5	Specialty Tier	1	2	010010		1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													379.00	25		25					379.00	25		25														25							25			25				25			25			
S5921	363	0		29	10	S5921_363_0	5	4	Non-Preferred Brand	1	2	100100		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										45.00		135.00						70.00		210.00															120.00							210.00				70.00					70.00			70.00				
S5921	363	0		29	10	S5921_363_0	5	3	Preferred Brand	1	2	010001		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										25.00		75.00						35.00		105.00															60.00							105.00				35.00					35.00			35.00				
S5921	363	0		29	10	S5921_363_0	5	1	Preferred Generic	1	2	001000		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													1.00		3.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	363	0		29	10	S5921_363_0	5	2	Non-Preferred Generic	1	2	000100		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						5.00		15.00															2.00							15.00				5.00					5.00							
S5921	364	0		29	10	S5921_364_0	5	4	Non-Preferred Brand	1	2	100100		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										45.00		135.00						70.00		210.00															120.00							210.00				70.00					70.00			70.00				
S5921	364	0		29	10	S5921_364_0	5	3	Preferred Brand	1	2	010001		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										25.00		75.00						35.00		105.00															60.00							105.00				35.00					35.00			35.00				
S5921	364	0		29	10	S5921_364_0	5	2	Non-Preferred Generic	1	2	000100		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						5.00		15.00															2.00							15.00				5.00					5.00							
S5921	364	0		29	10	S5921_364_0	5	1	Preferred Generic	1	2	001000		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													1.00		3.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	364	0		29	10	S5921_364_0	5	5	Specialty Tier	1	2	010010		1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													379.00	25		25					379.00	25		25														25							25			25				25			25			
S5921	365	0		29	10	S5921_365_0	5	3	Preferred Brand	1	2	010001		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										25.00		75.00						35.00		105.00															60.00							105.00				35.00					35.00			35.00				
S5921	365	0		29	10	S5921_365_0	5	4	Non-Preferred Brand	1	2	100100		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										45.00		135.00						70.00		210.00															120.00							210.00				70.00					70.00			70.00				
S5921	365	0		29	10	S5921_365_0	5	1	Preferred Generic	1	2	001000		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													1.00		3.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	365	0		29	10	S5921_365_0	5	2	Non-Preferred Generic	1	2	000100		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						5.00		15.00															2.00							15.00				5.00					5.00							
S5921	365	0		29	10	S5921_365_0	5	5	Specialty Tier	1	2	010010		1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													379.00	25		25					379.00	25		25														25							25			25				25			25			
S5921	366	0		29	10	S5921_366_0	5	1	Preferred Generic	1	2	001000		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													1.00		3.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	366	0		29	10	S5921_366_0	5	2	Non-Preferred Generic	1	2	000100		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						5.00		15.00															2.00							15.00				5.00					5.00							
S5921	366	0		29	10	S5921_366_0	5	3	Preferred Brand	1	2	010001		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										25.00		75.00						35.00		105.00															60.00							105.00				35.00					35.00			35.00				
S5921	366	0		29	10	S5921_366_0	5	4	Non-Preferred Brand	1	2	100100		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										45.00		135.00						70.00		210.00															120.00							210.00				70.00					70.00			70.00				
S5921	366	0		29	10	S5921_366_0	5	5	Specialty Tier	1	2	010010		1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													379.00	25		25					379.00	25		25														25							25			25				25			25			
S5921	367	0		29	10	S5921_367_0	5	1	Preferred Generic	1	2	001000		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													1.00		3.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	367	0		29	10	S5921_367_0	5	2	Non-Preferred Generic	1	2	000100		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						5.00		15.00															2.00							15.00				5.00					5.00							
S5921	367	0		29	10	S5921_367_0	5	3	Preferred Brand	1	2	010001		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										25.00		75.00						35.00		105.00															60.00							105.00				35.00					35.00			35.00				
S5921	367	0		29	10	S5921_367_0	5	4	Non-Preferred Brand	1	2	100100		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										45.00		135.00						70.00		210.00															120.00							210.00				70.00					70.00			70.00				
S5921	367	0		29	10	S5921_367_0	5	5	Specialty Tier	1	2	010010		1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													379.00	25		25					379.00	25		25														25							25			25				25			25			
S5921	368	0		29	10	S5921_368_0	5	1	Preferred Generic	1	2	001000		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													1.00		3.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	368	0		29	10	S5921_368_0	5	2	Non-Preferred Generic	1	2	000100		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						5.00		15.00															2.00							15.00				5.00					5.00							
S5921	368	0		29	10	S5921_368_0	5	3	Preferred Brand	1	2	010001		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										25.00		75.00						35.00		105.00															60.00							105.00				35.00					35.00			35.00				
S5921	368	0		29	10	S5921_368_0	5	4	Non-Preferred Brand	1	2	100100		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										45.00		135.00						70.00		210.00															120.00							210.00				70.00					70.00			70.00				
S5921	368	0		29	10	S5921_368_0	5	5	Specialty Tier	1	2	010010		1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													379.00	25		25					379.00	25		25														25							25			25				25			25			
S5921	369	0		29	10	S5921_369_0	5	2	Non-Preferred Generic	1	2	000100		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						5.00		15.00															2.00							15.00				5.00					5.00							
S5921	369	0		29	10	S5921_369_0	5	1	Preferred Generic	1	2	001000		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													1.00		3.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	369	0		29	10	S5921_369_0	5	5	Specialty Tier	1	2	010010		1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													379.00	25		25					379.00	25		25														25							25			25				25			25			
S5921	369	0		29	10	S5921_369_0	5	4	Non-Preferred Brand	1	2	100100		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										45.00		135.00						70.00		210.00															120.00							210.00				70.00					70.00			70.00				
S5921	369	0		29	10	S5921_369_0	5	3	Preferred Brand	1	2	010001		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										25.00		75.00						35.00		105.00															60.00							105.00				35.00					35.00			35.00				
S5921	370	0		29	10	S5921_370_0	5	3	Preferred Brand	1	2	010001		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										25.00		75.00						35.00		105.00															60.00							105.00				35.00					35.00			35.00				
S5921	370	0		29	10	S5921_370_0	5	1	Preferred Generic	1	2	001000		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													1.00		3.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	370	0		29	10	S5921_370_0	5	2	Non-Preferred Generic	1	2	000100		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						5.00		15.00															2.00							15.00				5.00					5.00							
S5921	370	0		29	10	S5921_370_0	5	4	Non-Preferred Brand	1	2	100100		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										45.00		135.00						70.00		210.00															120.00							210.00				70.00					70.00			70.00				
S5921	370	0		29	10	S5921_370_0	5	5	Specialty Tier	1	2	010010		1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													379.00	25		25					379.00	25		25														25							25			25				25			25			
S5921	371	0		29	10	S5921_371_0	5	4	Non-Preferred Brand	1	2	100100		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										45.00		135.00						70.00		210.00															120.00							210.00				70.00					70.00			70.00				
S5921	371	0		29	10	S5921_371_0	5	3	Preferred Brand	1	2	010001		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										25.00		75.00						35.00		105.00															60.00							105.00				35.00					35.00			35.00				
S5921	371	0		29	10	S5921_371_0	5	5	Specialty Tier	1	2	010010		1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													379.00	25		25					379.00	25		25														25							25			25				25			25			
S5921	371	0		29	10	S5921_371_0	5	2	Non-Preferred Generic	1	2	000100		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						5.00		15.00															2.00							15.00				5.00					5.00							
S5921	371	0		29	10	S5921_371_0	5	1	Preferred Generic	1	2	001000		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													1.00		3.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	372	0		29	10	S5921_372_0	5	5	Specialty Tier	1	2	010010		1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													379.00	25		25					379.00	25		25														25							25			25				25			25			
S5921	372	0		29	10	S5921_372_0	5	1	Preferred Generic	1	2	001000		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													1.00		3.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	372	0		29	10	S5921_372_0	5	2	Non-Preferred Generic	1	2	000100		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						5.00		15.00															2.00							15.00				5.00					5.00							
S5921	372	0		29	10	S5921_372_0	5	3	Preferred Brand	1	2	010001		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										25.00		75.00						35.00		105.00															60.00							105.00				35.00					35.00			35.00				
S5921	372	0		29	10	S5921_372_0	5	4	Non-Preferred Brand	1	2	100100		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										45.00		135.00						70.00		210.00															120.00							210.00				70.00					70.00			70.00				
S5921	373	0		29	10	S5921_373_0	5	5	Specialty Tier	1	2	010010		1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													379.00	25		25					379.00	25		25														25							25			25				25			25			
S5921	373	0		29	10	S5921_373_0	5	4	Non-Preferred Brand	1	2	100100		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										45.00		135.00						70.00		210.00															120.00							210.00				70.00					70.00			70.00				
S5921	373	0		29	10	S5921_373_0	5	3	Preferred Brand	1	2	010001		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										25.00		75.00						35.00		105.00															60.00							105.00				35.00					35.00			35.00				
S5921	373	0		29	10	S5921_373_0	5	2	Non-Preferred Generic	1	2	000100		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						5.00		15.00															2.00							15.00				5.00					5.00							
S5921	373	0		29	10	S5921_373_0	5	1	Preferred Generic	1	2	001000		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													1.00		3.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	374	0		29	10	S5921_374_0	5	5	Specialty Tier	1	2	010010		1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													379.00	25		25					379.00	25		25														25							25			25				25			25			
S5921	374	0		29	10	S5921_374_0	5	4	Non-Preferred Brand	1	2	100100		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										45.00		135.00						70.00		210.00															120.00							210.00				70.00					70.00			70.00				
S5921	374	0		29	10	S5921_374_0	5	2	Non-Preferred Generic	1	2	000100		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						5.00		15.00															2.00							15.00				5.00					5.00							
S5921	374	0		29	10	S5921_374_0	5	3	Preferred Brand	1	2	010001		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										25.00		75.00						35.00		105.00															60.00							105.00				35.00					35.00			35.00				
S5921	374	0		29	10	S5921_374_0	5	1	Preferred Generic	1	2	001000		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													1.00		3.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	375	0		29	10	S5921_375_0	5	1	Preferred Generic	1	2	001000		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													1.00		3.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	375	0		29	10	S5921_375_0	5	2	Non-Preferred Generic	1	2	000100		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						5.00		15.00															2.00							15.00				5.00					5.00							
S5921	375	0		29	10	S5921_375_0	5	5	Specialty Tier	1	2	010010		1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													379.00	25		25					379.00	25		25														25							25			25				25			25			
S5921	375	0		29	10	S5921_375_0	5	4	Non-Preferred Brand	1	2	100100		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										45.00		135.00						70.00		210.00															120.00							210.00				70.00					70.00			70.00				
S5921	375	0		29	10	S5921_375_0	5	3	Preferred Brand	1	2	010001		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										25.00		75.00						35.00		105.00															60.00							105.00				35.00					35.00			35.00				
S5921	376	0		29	10	S5921_376_0	5	5	Specialty Tier	1	2	010010		1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													379.00	25		25					379.00	25		25														25							25			25				25			25			
S5921	376	0		29	10	S5921_376_0	5	2	Non-Preferred Generic	1	2	000100		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						5.00		15.00															2.00							15.00				5.00					5.00							
S5921	376	0		29	10	S5921_376_0	5	1	Preferred Generic	1	2	001000		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													1.00		3.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	376	0		29	10	S5921_376_0	5	4	Non-Preferred Brand	1	2	100100		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										45.00		135.00						70.00		210.00															120.00							210.00				70.00					70.00			70.00				
S5921	376	0		29	10	S5921_376_0	5	3	Preferred Brand	1	2	010001		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										25.00		75.00						35.00		105.00															60.00							105.00				35.00					35.00			35.00				
S5921	377	0		29	10	S5921_377_0	5	2	Non-Preferred Generic	1	2	000100		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													2.00		6.00						5.00		15.00															2.00							15.00				5.00					5.00							
S5921	377	0		29	10	S5921_377_0	5	1	Preferred Generic	1	2	001000		2	000010110110000001001100				31		90	31		90	1						90			90	31		31													1.00		3.00						4.00		12.00															0.00							12.00				4.00					4.00							
S5921	377	0		29	10	S5921_377_0	5	3	Preferred Brand	1	2	010001		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										25.00		75.00						35.00		105.00															60.00							105.00				35.00					35.00			35.00				
S5921	377	0		29	10	S5921_377_0	5	4	Non-Preferred Brand	1	2	100100		2	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14										45.00		135.00						70.00		210.00															120.00							210.00				70.00					70.00			70.00				
S5921	377	0		29	10	S5921_377_0	5	5	Specialty Tier	1	2	010010		1	100010110110000001001101				31		90	31		90	1						90			90	31		31		31	14													380.00	25		25					380.00	25		25														25							25			25				25			25			
S5937	001	0		29	10	S5937_001_0	3	3	Specialty Tier	1	3	001001		1	110100000010101000000111	34		90							1	34		90							34		34	14	34	14					48.48	25		25																					25		25																	25				25			25			
S5937	001	0		29	10	S5937_001_0	3	2	Preferred Brand	1	3	000001		2	110100000010101000000001	34		90							1	34		90							34				34	14		44.00		132.00																						44.00		132.00																		44.00								44.00				
S5937	001	0		29	10	S5937_001_0	3	1	Preferred Generic	1	3	001000		2	010100000010101000000110	34		90							1	34		90							34		34	14				6.00		18.00																						6.00		18.00																		6.00					6.00							
S5937	002	0		29	10	S5937_002_0	4	3	Specialty Tier	1	4	001001	1	1	110100000010101000000111	34		90							1	34		90							34		34	14	34	14					53.82	30		30																					30		30																	30				30			30			
S5937	002	0		29	10	S5937_002_0	4	2	Preferred Brand	1	4	000001	1	2	110100000010101000000001	34		90							1	34		90							34				34	14		35.00		105.00																						35.00		105.00																		35.00								35.00				
S5937	002	0		29	10	S5937_002_0	4	1	Preferred Generic	3	4	001000	1	2	010100000010101000000110	34		90							1	34		90							34		34	14				5.00		15.00																						5.00		15.00																		5.00					5.00					1		
S5937	002	0		29	10	S5937_002_0	4	1	Preferred Generic	1	4	001000	1	2	010100000010101000000110	34		90							1	34		90							34		34	14				5.00		15.00																						5.00		15.00																		5.00					5.00							
S5953	001	0		29	10	S5953_001_0	5	2	Preferred Brand	1	3	000001		2	110100000010000101101001	31		90							1				31		90	31		90	31				31	14		40.00		120.00																													40.00		100.00					40.00		120.00				40.00								40.00				
S5953	001	0		29	10	S5953_001_0	5	1	Generic	1	3	010000		2	010100000010000101101100	31		90							1				31		90	31		90	31		31					5.00		15.00																													5.00		12.50					5.00		15.00				5.00					5.00							
S5953	001	0		29	10	S5953_001_0	5	4	Specialty Tier	1	3	010010		1	110100000010000101101101	31		90							1				31		90	31		90	31		31		31	14					25.00	25		25																												25		25					25		25			25				25			25			
S5953	001	0		29	10	S5953_001_0	5	3	Non-Preferred Brand	1	3	100000		2	110100000010000101101001	31		90							1				31		90	31		90	31				31	14		80.00		240.00																													80.00		200.00					80.00		240.00				80.00								80.00				
S5953	002	0		29	10	S5953_002_0	6	5	Specialty Tier	1	4	010010	1	1	110100000010000101101101	31		90							1				31		90	31		90	31		31		31	14					33.00	33		33																												33		33					33		33			33				33			33			
S5953	002	0		29	10	S5953_002_0	6	1	Preferred Generic	3	4	001000	1	2	010100000010000101101100	31		90							1				31		90	31		90	31		31					2.00		6.00																													2.00		4.00					2.00		6.00				2.00					2.00					1		
S5953	002	0		29	10	S5953_002_0	6	4	Non-Preferred Brand	1	4	100000	1	2	110100000010000101101001	31		90							1				31		90	31		90	31				31	14		74.00		222.00																													74.00		185.00					74.00		222.00				74.00								74.00				
S5953	002	0		29	10	S5953_002_0	6	3	Preferred Brand	1	4	000001	1	2	110100000010000101101001	31		90							1				31		90	31		90	31				31	14		33.00		99.00																													33.00		82.50					33.00		99.00				33.00								33.00				
S5953	002	0		29	10	S5953_002_0	6	2	Non-Preferred Generic	3	4	000100	1	2	010100000010000101101100	31		90							1				31		90	31		90	31		31					7.00		21.00																													7.00		17.50					7.00		21.00				7.00					7.00					1		
S5953	002	0		29	10	S5953_002_0	6	1	Preferred Generic	1	4	001000	1	2	010100000010000101101100	31		90							1				31		90	31		90	31		31					2.00		6.00																													2.00		4.00					2.00		6.00				2.00					2.00							
S5953	002	0		29	10	S5953_002_0	6	2	Non-Preferred Generic	1	4	000100	1	2	010100000010000101101100	31		90							1				31		90	31		90	31		31					7.00		21.00																													7.00		17.50					7.00		21.00				7.00					7.00							
S5960	108	0		29	10	S5960_108_0	4	1	Preferred Generic	1	2	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5960	108	0		29	10	S5960_108_0	4	2	Non-Preferred Generic	1	2	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5960	108	0		29	10	S5960_108_0	4	3	Preferred Brand	1	2	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		33.00	66.00	99.00																						33.00	82.50	82.50																		33.00					33.00			33.00				
S5960	108	0		29	10	S5960_108_0	4	4	Non-Preferred Brand	1	2	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		85.00	170.00	255.00																						85.00	212.50	212.50																		85.00					85.00			85.00				
S5960	108	0		29	10	S5960_108_0	4	5	Injectable Drugs	1	2	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					97.75	25	25	25																					25	25	25																	25				25			25			
S5960	108	0		29	10	S5960_108_0	4	6	Specialty Tier	1	2	010010		1	110000000010100000000111	30										30									30		34	14	34	14					435.00	25																							25																			25				25			25			
S5960	109	0		29	10	S5960_109_0	3	1	Preferred Generic	1	2	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5960	109	0		29	10	S5960_109_0	3	2	Non-Preferred Generic	1	2	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5960	109	0		29	10	S5960_109_0	3	3	Preferred Brand	1	2	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		36.00	72.00	108.00																						36.00	90.00	90.00																		36.00					36.00			36.00				
S5960	109	0		29	10	S5960_109_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		85.00	170.00	255.00																						85.00	212.50	212.50																		85.00					85.00			85.00				
S5960	109	0		29	10	S5960_109_0	3	5	Injectable Drugs	1	2	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					85.25	25	25	25																					25	25	25																	25				25			25			
S5960	109	0		29	10	S5960_109_0	3	6	Specialty Tier	1	2	010010		1	110000000010100000000111	30										30									30		34	14	34	14					417.75	25																							25																			25				25			25			
S5960	110	0		29	10	S5960_110_0	3	1	Preferred Generic	1	2	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5960	110	0		29	10	S5960_110_0	3	2	Non-Preferred Generic	1	2	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5960	110	0		29	10	S5960_110_0	3	6	Specialty Tier	1	2	010010		1	110000000010100000000111	30										30									30		34	14	34	14					519.50	25																							25																			25				25			25			
S5960	110	0		29	10	S5960_110_0	3	5	Injectable Drugs	1	2	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					92.25	25	25	25																					25	25	25																	25				25			25			
S5960	110	0		29	10	S5960_110_0	3	3	Preferred Brand	1	2	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		41.00	82.00	123.00																						41.00	102.50	102.50																		41.00					41.00			41.00				
S5960	110	0		29	10	S5960_110_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		85.00	170.00	255.00																						85.00	212.50	212.50																		85.00					85.00			85.00				
S5960	111	0		29	10	S5960_111_0	3	6	Specialty Tier	1	2	010010		1	110000000010100000000111	30										30									30		34	14	34	14					383.00	25																							25																			25				25			25			
S5960	111	0		29	10	S5960_111_0	3	1	Preferred Generic	1	2	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5960	111	0		29	10	S5960_111_0	3	2	Non-Preferred Generic	1	2	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5960	111	0		29	10	S5960_111_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		85.00	170.00	255.00																						85.00	212.50	212.50																		85.00					85.00			85.00				
S5960	111	0		29	10	S5960_111_0	3	3	Preferred Brand	1	2	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		36.00	72.00	108.00																						36.00	90.00	90.00																		36.00					36.00			36.00				
S5960	111	0		29	10	S5960_111_0	3	5	Injectable Drugs	1	2	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					68.25	25	25	25																					25	25	25																	25				25			25			
S5960	112	0		29	10	S5960_112_0	3	6	Specialty Tier	1	2	010010		1	110000000010100000000111	30										30									30		34	14	34	14					462.50	25																							25																			25				25			25			
S5960	112	0		29	10	S5960_112_0	3	5	Injectable Drugs	1	2	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					92.50	25	25	25																					25	25	25																	25				25			25			
S5960	112	0		29	10	S5960_112_0	3	1	Preferred Generic	1	2	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5960	112	0		29	10	S5960_112_0	3	2	Non-Preferred Generic	1	2	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5960	112	0		29	10	S5960_112_0	3	3	Preferred Brand	1	2	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		31.00	62.00	93.00																						31.00	77.50	77.50																		31.00					31.00			31.00				
S5960	112	0		29	10	S5960_112_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		85.00	170.00	255.00																						85.00	212.50	212.50																		85.00					85.00			85.00				
S5960	114	0		29	10	S5960_114_0	3	3	Preferred Brand	1	2	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		29.00	58.00	87.00																						29.00	72.50	72.50																		29.00					29.00			29.00				
S5960	114	0		29	10	S5960_114_0	3	5	Injectable Drugs	1	2	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					85.00	25	25	25																					25	25	25																	25				25			25			
S5960	114	0		29	10	S5960_114_0	3	6	Specialty Tier	1	2	010010		1	110000000010100000000111	30										30									30		34	14	34	14					519.25	25																							25																			25				25			25			
S5960	114	0		29	10	S5960_114_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		85.00	170.00	255.00																						85.00	212.50	212.50																		85.00					85.00			85.00				
S5960	114	0		29	10	S5960_114_0	3	2	Non-Preferred Generic	1	2	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5960	114	0		29	10	S5960_114_0	3	1	Preferred Generic	1	2	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5960	115	0		29	10	S5960_115_0	3	5	Injectable Drugs	1	2	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					106.00	25	25	25																					25	25	25																	25				25			25			
S5960	115	0		29	10	S5960_115_0	3	6	Specialty Tier	1	2	010010		1	110000000010100000000111	30										30									30		34	14	34	14					527.50	25																							25																			25				25			25			
S5960	115	0		29	10	S5960_115_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		85.00	170.00	255.00																						85.00	212.50	212.50																		85.00					85.00			85.00				
S5960	115	0		29	10	S5960_115_0	3	3	Preferred Brand	1	2	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		31.00	62.00	93.00																						31.00	77.50	77.50																		31.00					31.00			31.00				
S5960	115	0		29	10	S5960_115_0	3	2	Non-Preferred Generic	1	2	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5960	115	0		29	10	S5960_115_0	3	1	Preferred Generic	1	2	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5960	117	0		29	10	S5960_117_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		85.00	170.00	255.00																						85.00	212.50	212.50																		85.00					85.00			85.00				
S5960	117	0		29	10	S5960_117_0	3	3	Preferred Brand	1	2	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		39.00	78.00	117.00																						39.00	97.50	97.50																		39.00					39.00			39.00				
S5960	117	0		29	10	S5960_117_0	3	2	Non-Preferred Generic	1	2	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5960	117	0		29	10	S5960_117_0	3	1	Preferred Generic	1	2	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5960	117	0		29	10	S5960_117_0	3	5	Injectable Drugs	1	2	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					78.50	25	25	25																					25	25	25																	25				25			25			
S5960	117	0		29	10	S5960_117_0	3	6	Specialty Tier	1	2	010010		1	110000000010100000000111	30										30									30		34	14	34	14					380.75	25																							25																			25				25			25			
S5960	118	0		29	10	S5960_118_0	3	1	Preferred Generic	1	2	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5960	118	0		29	10	S5960_118_0	3	2	Non-Preferred Generic	1	2	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5960	118	0		29	10	S5960_118_0	3	3	Preferred Brand	1	2	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		30.00	60.00	90.00																						30.00	75.00	75.00																		30.00					30.00			30.00				
S5960	118	0		29	10	S5960_118_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		85.00	170.00	255.00																						85.00	212.50	212.50																		85.00					85.00			85.00				
S5960	118	0		29	10	S5960_118_0	3	5	Injectable Drugs	1	2	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					69.00	25	25	25																					25	25	25																	25				25			25			
S5960	118	0		29	10	S5960_118_0	3	6	Specialty Tier	1	2	010010		1	110000000010100000000111	30										30									30		34	14	34	14					550.00	25																							25																			25				25			25			
S5960	119	0		29	10	S5960_119_0	3	1	Preferred Generic	1	2	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5960	119	0		29	10	S5960_119_0	3	2	Non-Preferred Generic	1	2	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5960	119	0		29	10	S5960_119_0	3	3	Preferred Brand	1	2	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	112.50	112.50																		45.00					45.00			45.00				
S5960	119	0		29	10	S5960_119_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		85.00	170.00	255.00																						85.00	212.50	212.50																		85.00					85.00			85.00				
S5960	119	0		29	10	S5960_119_0	3	5	Injectable Drugs	1	2	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					74.75	25	25	25																					25	25	25																	25				25			25			
S5960	119	0		29	10	S5960_119_0	3	6	Specialty Tier	1	2	010010		1	110000000010100000000111	30										30									30		34	14	34	14					530.25	25																							25																			25				25			25			
S5960	123	0		29	10	S5960_123_0	3	1	Preferred Generic	1	2	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5960	123	0		29	10	S5960_123_0	3	2	Non-Preferred Generic	1	2	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5960	123	0		29	10	S5960_123_0	3	3	Preferred Brand	1	2	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		34.00	68.00	102.00																						34.00	85.00	85.00																		34.00					34.00			34.00				
S5960	123	0		29	10	S5960_123_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		85.00	170.00	255.00																						85.00	212.50	212.50																		85.00					85.00			85.00				
S5960	123	0		29	10	S5960_123_0	3	5	Injectable Drugs	1	2	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					58.25	25	25	25																					25	25	25																	25				25			25			
S5960	123	0		29	10	S5960_123_0	3	6	Specialty Tier	1	2	010010		1	110000000010100000000111	30										30									30		34	14	34	14					552.50	25																							25																			25				25			25			
S5960	125	0		29	10	S5960_125_0	3	5	Injectable Drugs	1	2	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					52.75	25	25	25																					25	25	25																	25				25			25			
S5960	125	0		29	10	S5960_125_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		85.00	170.00	255.00																						85.00	212.50	212.50																		85.00					85.00			85.00				
S5960	125	0		29	10	S5960_125_0	3	6	Specialty Tier	1	2	010010		1	110000000010100000000111	30										30									30		34	14	34	14					528.50	25																							25																			25				25			25			
S5960	125	0		29	10	S5960_125_0	3	2	Non-Preferred Generic	1	2	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5960	125	0		29	10	S5960_125_0	3	1	Preferred Generic	1	2	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5960	125	0		29	10	S5960_125_0	3	3	Preferred Brand	1	2	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		29.00	58.00	87.00																						29.00	72.50	72.50																		29.00					29.00			29.00				
S5960	126	0		29	10	S5960_126_0	3	2	Non-Preferred Generic	1	2	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5960	126	0		29	10	S5960_126_0	3	3	Preferred Brand	1	2	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		26.00	52.00	78.00																						26.00	65.00	65.00																		26.00					26.00			26.00				
S5960	126	0		29	10	S5960_126_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		85.00	170.00	255.00																						85.00	212.50	212.50																		85.00					85.00			85.00				
S5960	126	0		29	10	S5960_126_0	3	5	Injectable Drugs	1	2	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					67.00	25	25	25																					25	25	25																	25				25			25			
S5960	126	0		29	10	S5960_126_0	3	6	Specialty Tier	1	2	010010		1	110000000010100000000111	30										30									30		34	14	34	14					545.00	25																							25																			25				25			25			
S5960	126	0		29	10	S5960_126_0	3	1	Preferred Generic	1	2	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5960	127	0		29	10	S5960_127_0	3	6	Specialty Tier	1	2	010010		1	110000000010100000000111	30										30									30		34	14	34	14					444.00	25																							25																			25				25			25			
S5960	127	0		29	10	S5960_127_0	3	5	Injectable Drugs	1	2	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					73.25	25	25	25																					25	25	25																	25				25			25			
S5960	127	0		29	10	S5960_127_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		85.00	170.00	255.00																						85.00	212.50	212.50																		85.00					85.00			85.00				
S5960	127	0		29	10	S5960_127_0	3	3	Preferred Brand	1	2	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		29.00	58.00	87.00																						29.00	72.50	72.50																		29.00					29.00			29.00				
S5960	127	0		29	10	S5960_127_0	3	2	Non-Preferred Generic	1	2	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5960	127	0		29	10	S5960_127_0	3	1	Preferred Generic	1	2	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5960	128	0		29	10	S5960_128_0	3	6	Specialty Tier	1	2	010010		1	110000000010100000000111	30										30									30		34	14	34	14					488.00	25																							25																			25				25			25			
S5960	128	0		29	10	S5960_128_0	3	5	Injectable Drugs	1	2	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					68.50	25	25	25																					25	25	25																	25				25			25			
S5960	128	0		29	10	S5960_128_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		85.00	170.00	255.00																						85.00	212.50	212.50																		85.00					85.00			85.00				
S5960	128	0		29	10	S5960_128_0	3	3	Preferred Brand	1	2	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		35.00	70.00	105.00																						35.00	87.50	87.50																		35.00					35.00			35.00				
S5960	128	0		29	10	S5960_128_0	3	2	Non-Preferred Generic	1	2	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5960	128	0		29	10	S5960_128_0	3	1	Preferred Generic	1	2	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5960	129	0		29	10	S5960_129_0	3	6	Specialty Tier	1	2	010010		1	110000000010100000000111	30										30									30		34	14	34	14					529.25	25																							25																			25				25			25			
S5960	129	0		29	10	S5960_129_0	3	5	Injectable Drugs	1	2	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					89.25	25	25	25																					25	25	25																	25				25			25			
S5960	129	0		29	10	S5960_129_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		85.00	170.00	255.00																						85.00	212.50	212.50																		85.00					85.00			85.00				
S5960	129	0		29	10	S5960_129_0	3	3	Preferred Brand	1	2	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		34.00	68.00	102.00																						34.00	85.00	85.00																		34.00					34.00			34.00				
S5960	129	0		29	10	S5960_129_0	3	2	Non-Preferred Generic	1	2	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5960	129	0		29	10	S5960_129_0	3	1	Preferred Generic	1	2	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5960	130	0		29	10	S5960_130_0	3	5	Injectable Drugs	1	2	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					97.50	25	25	25																					25	25	25																	25				25			25			
S5960	130	0		29	10	S5960_130_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		85.00	170.00	255.00																						85.00	212.50	212.50																		85.00					85.00			85.00				
S5960	130	0		29	10	S5960_130_0	3	3	Preferred Brand	1	2	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		29.00	58.00	87.00																						29.00	72.50	72.50																		29.00					29.00			29.00				
S5960	130	0		29	10	S5960_130_0	3	2	Non-Preferred Generic	1	2	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5960	130	0		29	10	S5960_130_0	3	1	Preferred Generic	1	2	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5960	130	0		29	10	S5960_130_0	3	6	Specialty Tier	1	2	010010		1	110000000010100000000111	30										30									30		34	14	34	14					379.00	25																							25																			25				25			25			
S5960	131	0		29	10	S5960_131_0	3	6	Specialty Tier	1	2	010010		1	110000000010100000000111	30										30									30		34	14	34	14					526.50	25																							25																			25				25			25			
S5960	131	0		29	10	S5960_131_0	3	5	Injectable Drugs	1	2	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					61.50	25	25	25																					25	25	25																	25				25			25			
S5960	131	0		29	10	S5960_131_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		85.00	170.00	255.00																						85.00	212.50	212.50																		85.00					85.00			85.00				
S5960	131	0		29	10	S5960_131_0	3	3	Preferred Brand	1	2	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		29.00	58.00	87.00																						29.00	72.50	72.50																		29.00					29.00			29.00				
S5960	131	0		29	10	S5960_131_0	3	1	Preferred Generic	1	2	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5960	131	0		29	10	S5960_131_0	3	2	Non-Preferred Generic	1	2	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5960	132	0		29	10	S5960_132_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		85.00	170.00	255.00																						85.00	212.50	212.50																		85.00					85.00			85.00				
S5960	132	0		29	10	S5960_132_0	3	5	Injectable Drugs	1	2	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					57.75	25	25	25																					25	25	25																	25				25			25			
S5960	132	0		29	10	S5960_132_0	3	6	Specialty Tier	1	2	010010		1	110000000010100000000111	30										30									30		34	14	34	14					441.75	25																							25																			25				25			25			
S5960	132	0		29	10	S5960_132_0	3	1	Preferred Generic	1	2	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5960	132	0		29	10	S5960_132_0	3	2	Non-Preferred Generic	1	2	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5960	132	0		29	10	S5960_132_0	3	3	Preferred Brand	1	2	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		33.00	66.00	99.00																						33.00	82.50	82.50																		33.00					33.00			33.00				
S5960	134	0		29	10	S5960_134_0	3	1	Preferred Generic	1	2	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5960	134	0		29	10	S5960_134_0	3	2	Non-Preferred Generic	1	2	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5960	134	0		29	10	S5960_134_0	3	3	Preferred Brand	1	2	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		30.00	60.00	90.00																						30.00	75.00	75.00																		30.00					30.00			30.00				
S5960	134	0		29	10	S5960_134_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		85.00	170.00	255.00																						85.00	212.50	212.50																		85.00					85.00			85.00				
S5960	134	0		29	10	S5960_134_0	3	5	Injectable Drugs	1	2	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					60.00	25	25	25																					25	25	25																	25				25			25			
S5960	134	0		29	10	S5960_134_0	3	6	Specialty Tier	1	2	010010		1	110000000010100000000111	30										30									30		34	14	34	14					473.50	25																							25																			25				25			25			
S5960	136	0		29	10	S5960_136_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		85.00	170.00	255.00																						85.00	212.50	212.50																		85.00					85.00			85.00				
S5960	136	0		29	10	S5960_136_0	3	6	Specialty Tier	1	2	010010		1	110000000010100000000111	30										30									30		34	14	34	14					425.75	25																							25																			25				25			25			
S5960	136	0		29	10	S5960_136_0	3	5	Injectable Drugs	1	2	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					62.00	25	25	25																					25	25	25																	25				25			25			
S5960	136	0		29	10	S5960_136_0	3	1	Preferred Generic	1	2	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5960	136	0		29	10	S5960_136_0	3	2	Non-Preferred Generic	1	2	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5960	136	0		29	10	S5960_136_0	3	3	Preferred Brand	1	2	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		34.00	68.00	102.00																						34.00	85.00	85.00																		34.00					34.00			34.00				
S5960	137	0		29	10	S5960_137_0	3	5	Injectable Drugs	1	2	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					70.25	25	25	25																					25	25	25																	25				25			25			
S5960	137	0		29	10	S5960_137_0	3	6	Specialty Tier	1	2	010010		1	110000000010100000000111	30										30									30		34	14	34	14					579.50	25																							25																			25				25			25			
S5960	137	0		29	10	S5960_137_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		85.00	170.00	255.00																						85.00	212.50	212.50																		85.00					85.00			85.00				
S5960	137	0		29	10	S5960_137_0	3	3	Preferred Brand	1	2	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		37.00	74.00	111.00																						37.00	92.50	92.50																		37.00					37.00			37.00				
S5960	137	0		29	10	S5960_137_0	3	2	Non-Preferred Generic	1	2	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5960	137	0		29	10	S5960_137_0	3	1	Preferred Generic	1	2	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5960	139	0		29	10	S5960_139_0	3	2	Non-Preferred Generic	1	2	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5960	139	0		29	10	S5960_139_0	3	3	Preferred Brand	1	2	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		31.00	62.00	93.00																						31.00	77.50	77.50																		31.00					31.00			31.00				
S5960	139	0		29	10	S5960_139_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		85.00	170.00	255.00																						85.00	212.50	212.50																		85.00					85.00			85.00				
S5960	139	0		29	10	S5960_139_0	3	5	Injectable Drugs	1	2	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					86.50	25	25	25																					25	25	25																	25				25			25			
S5960	139	0		29	10	S5960_139_0	3	1	Preferred Generic	1	2	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5960	139	0		29	10	S5960_139_0	3	6	Specialty Tier	1	2	010010		1	110000000010100000000111	30										30									30		34	14	34	14					335.00	25																							25																			25				25			25			
S5960	140	0		29	10	S5960_140_0	3	5	Injectable Drugs	1	2	010010		1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					64.25	25	25	25																					25	25	25																	25				25			25			
S5960	140	0		29	10	S5960_140_0	3	3	Preferred Brand	1	2	000101		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		32.00	64.00	96.00																						32.00	80.00	80.00																		32.00					32.00			32.00				
S5960	140	0		29	10	S5960_140_0	3	4	Non-Preferred Brand	1	2	100100		2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		85.00	170.00	255.00																						85.00	212.50	212.50																		85.00					85.00			85.00				
S5960	140	0		29	10	S5960_140_0	3	6	Specialty Tier	1	2	010010		1	110000000010100000000111	30										30									30		34	14	34	14					372.75	25																							25																			25				25			25			
S5960	140	0		29	10	S5960_140_0	3	2	Non-Preferred Generic	1	2	000100		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				6.00	12.00	18.00																						6.00	9.00	9.00																		6.00					6.00							
S5960	140	0		29	10	S5960_140_0	3	1	Preferred Generic	1	2	001000		2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				2.00	4.00	6.00																						2.00	3.00	3.00																		2.00					2.00							
S5960	144	0		29	10	S5960_144_0	3	5	Injectable Drugs	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					94.38	33	33	33																					33	33	33																	33				33			33			
S5960	144	0		29	10	S5960_144_0	3	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		90.00	180.00	270.00																						90.00	225.00	225.00																		90.00					90.00			90.00				
S5960	144	0		29	10	S5960_144_0	3	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	112.50	112.50																		45.00					45.00			45.00				
S5960	144	0		29	10	S5960_144_0	3	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5960	144	0		29	10	S5960_144_0	3	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				4.00	8.00	12.00																						4.00	6.00	6.00																		4.00					4.00							
S5960	144	0		29	10	S5960_144_0	3	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00					1		
S5960	144	0		29	10	S5960_144_0	3	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					766.26	33																							33																			33				33			33			
S5960	147	0		29	10	S5960_147_0	3	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				4.00	8.00	12.00																						4.00	6.00	6.00																		4.00					4.00							
S5960	147	0		29	10	S5960_147_0	3	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00					1		
S5960	147	0		29	10	S5960_147_0	3	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	112.50	112.50																		45.00					45.00			45.00				
S5960	147	0		29	10	S5960_147_0	3	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		90.00	180.00	270.00																						90.00	225.00	225.00																		90.00					90.00			90.00				
S5960	147	0		29	10	S5960_147_0	3	5	Injectable Drugs	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					88.77	33	33	33																					33	33	33																	33				33			33			
S5960	147	0		29	10	S5960_147_0	3	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					564.63	33																							33																			33				33			33			
S5960	147	0		29	10	S5960_147_0	3	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5960	148	0		29	10	S5960_148_0	3	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00					1		
S5960	148	0		29	10	S5960_148_0	3	5	Injectable Drugs	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					80.19	33	33	33																					33	33	33																	33				33			33			
S5960	148	0		29	10	S5960_148_0	3	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					647.13	33																							33																			33				33			33			
S5960	148	0		29	10	S5960_148_0	3	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		90.00	180.00	270.00																						90.00	225.00	225.00																		90.00					90.00			90.00				
S5960	148	0		29	10	S5960_148_0	3	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	112.50	112.50																		45.00					45.00			45.00				
S5960	148	0		29	10	S5960_148_0	3	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5960	148	0		29	10	S5960_148_0	3	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				4.00	8.00	12.00																						4.00	6.00	6.00																		4.00					4.00							
S5960	157	0		29	10	S5960_157_0	3	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	112.50	112.50																		45.00					45.00			45.00				
S5960	157	0		29	10	S5960_157_0	3	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					837.87	33																							33																			33				33			33			
S5960	157	0		29	10	S5960_157_0	3	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00					1		
S5960	157	0		29	10	S5960_157_0	3	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5960	157	0		29	10	S5960_157_0	3	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				4.00	8.00	12.00																						4.00	6.00	6.00																		4.00					4.00							
S5960	157	0		29	10	S5960_157_0	3	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		90.00	180.00	270.00																						90.00	225.00	225.00																		90.00					90.00			90.00				
S5960	157	0		29	10	S5960_157_0	3	5	Injectable Drugs	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					61.38	33	33	33																					33	33	33																	33				33			33			
S5960	158	0		29	10	S5960_158_0	3	6	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		34	14	34	14					465.30	33																							33																			33				33			33			
S5960	158	0		29	10	S5960_158_0	3	5	Injectable Drugs	1	4	010010	1	1	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14					62.70	33	33	33																					33	33	33																	33				33			33			
S5960	158	0		29	10	S5960_158_0	3	4	Non-Preferred Brand	1	4	100100	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		90.00	180.00	270.00																						90.00	225.00	225.00																		90.00					90.00			90.00				
S5960	158	0		29	10	S5960_158_0	3	1	Preferred Generic	1	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				4.00	8.00	12.00																						4.00	6.00	6.00																		4.00					4.00							
S5960	158	0		29	10	S5960_158_0	3	1	Preferred Generic	3	4	001000	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00					1		
S5960	158	0		29	10	S5960_158_0	3	3	Preferred Brand	1	4	000101	1	2	111100000010111000000111	30	60	90							1	30	60	90							30		34	14	34	14		45.00	90.00	135.00																						45.00	112.50	112.50																		45.00					45.00			45.00				
S5960	158	0		29	10	S5960_158_0	3	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000110	30	60	90							1	30	60	90							30		34	14				7.00	14.00	21.00																						7.00	10.50	10.50																		7.00					7.00							
S5966	001	0		29	10	S5966_001_0	8	1	Preferred Generic	1	2	001000		2	011100000010111000000100	30	60	90							2	30	60	90							30		31					4.00	8.00	8.00																						4.00	8.00	8.00																		4.00					4.00							
S5966	001	0		29	10	S5966_001_0	8	4	Specialty Tier	1	2	010010		1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					723.79	25	25	25																					25	25	25																	25				25			25			
S5966	001	0		29	10	S5966_001_0	8	3	Preferred Brand	1	2	010001		1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					67.65	25	25	25																					25	25	25																	25				25			25			
S5966	001	0		29	10	S5966_001_0	8	2	Non-Preferred Generic	1	2	100100		1	111100000010111000000101	30	60	90							2	30	60	90							30		31		31	14					51.90	25	25	25																					25	25	25																	25				25			25			
S5967	138	0		29	10	S5967_138_0	3	1	Preferred Generic	1	3	001010		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		7.00	14.00	21.00																													7.00	14.00	0.00							21.00				7.00					7.00			7.00				
S5967	138	0		29	10	S5967_138_0	3	4	Specialty Tier	1	3	010010		1	110000000010000100100101	31													31			31			31		31		31	14					933.24	33																														33							33					33				33			33			
S5967	138	0		29	10	S5967_138_0	3	3	Non-Preferred Brand	1	3	110000		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		95.00	190.00	285.00																													95.00	190.00	190.00							285.00				95.00					95.00			95.00				
S5967	138	0		29	10	S5967_138_0	3	2	Preferred Brand	1	3	010001		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		43.00	86.00	129.00																													43.00	86.00	86.00							129.00				43.00					43.00			43.00				
S5967	139	0		29	10	S5967_139_0	3	2	Preferred Brand	1	3	010001		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		44.00	88.00	132.00																													44.00	88.00	88.00							132.00				44.00					44.00			44.00				
S5967	139	0		29	10	S5967_139_0	3	3	Non-Preferred Brand	1	3	110000		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		94.00	188.00	282.00																													94.00	188.00	188.00							282.00				94.00					94.00			94.00				
S5967	139	0		29	10	S5967_139_0	3	4	Specialty Tier	1	3	010010		1	110000000010000100100101	31													31			31			31		31		31	14					933.24	33																														33							33					33				33			33			
S5967	139	0		29	10	S5967_139_0	3	1	Preferred Generic	1	3	001010		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		6.00	12.00	18.00																													6.00	12.00	0.00							18.00				6.00					6.00			6.00				
S5967	140	0		29	10	S5967_140_0	3	2	Preferred Brand	1	3	010001		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		43.00	86.00	129.00																													43.00	86.00	86.00							129.00				43.00					43.00			43.00				
S5967	140	0		29	10	S5967_140_0	3	1	Preferred Generic	1	3	001010		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		6.00	12.00	18.00																													6.00	12.00	0.00							18.00				6.00					6.00			6.00				
S5967	140	0		29	10	S5967_140_0	3	3	Non-Preferred Brand	1	3	110000		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		94.00	188.00	282.00																													94.00	188.00	188.00							282.00				94.00					94.00			94.00				
S5967	140	0		29	10	S5967_140_0	3	4	Specialty Tier	1	3	010010		1	110000000010000100100101	31													31			31			31		31		31	14					933.24	33																														33							33					33				33			33			
S5967	141	0		29	10	S5967_141_0	3	3	Non-Preferred Brand	1	3	110000		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		93.00	186.00	279.00																													93.00	186.00	186.00							279.00				93.00					93.00			93.00				
S5967	141	0		29	10	S5967_141_0	3	4	Specialty Tier	1	3	010010		1	110000000010000100100101	31													31			31			31		31		31	14					933.24	33																														33							33					33				33			33			
S5967	141	0		29	10	S5967_141_0	3	1	Preferred Generic	1	3	001010		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		7.00	14.00	21.00																													7.00	14.00	0.00							21.00				7.00					7.00			7.00				
S5967	141	0		29	10	S5967_141_0	3	2	Preferred Brand	1	3	010001		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		42.00	84.00	126.00																													42.00	84.00	84.00							126.00				42.00					42.00			42.00				
S5967	142	0		29	10	S5967_142_0	3	1	Preferred Generic	1	3	001010		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		7.00	14.00	21.00																													7.00	14.00	0.00							21.00				7.00					7.00			7.00				
S5967	142	0		29	10	S5967_142_0	3	2	Preferred Brand	1	3	010001		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		42.00	84.00	126.00																													42.00	84.00	84.00							126.00				42.00					42.00			42.00				
S5967	142	0		29	10	S5967_142_0	3	4	Specialty Tier	1	3	010010		1	110000000010000100100101	31													31			31			31		31		31	14					933.24	33																														33							33					33				33			33			
S5967	142	0		29	10	S5967_142_0	3	3	Non-Preferred Brand	1	3	110000		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		92.00	184.00	276.00																													92.00	184.00	184.00							276.00				92.00					92.00			92.00				
S5967	143	0		29	10	S5967_143_0	3	4	Specialty Tier	1	3	010010		1	110000000010000100100101	31													31			31			31		31		31	14					933.24	33																														33							33					33				33			33			
S5967	143	0		29	10	S5967_143_0	3	3	Non-Preferred Brand	1	3	110000		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		91.00	182.00	273.00																													91.00	182.00	182.00							273.00				91.00					91.00			91.00				
S5967	143	0		29	10	S5967_143_0	3	2	Preferred Brand	1	3	010001		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		43.00	86.00	129.00																													43.00	86.00	86.00							129.00				43.00					43.00			43.00				
S5967	143	0		29	10	S5967_143_0	3	1	Preferred Generic	1	3	001010		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		5.00	10.00	15.00																													5.00	10.00	0.00							15.00				5.00					5.00			5.00				
S5967	144	0		29	10	S5967_144_0	3	4	Specialty Tier	1	3	010010		1	110000000010000100100101	31													31			31			31		31		31	14					933.24	33																														33							33					33				33			33			
S5967	144	0		29	10	S5967_144_0	3	1	Preferred Generic	1	3	001010		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		5.00	10.00	15.00																													5.00	10.00	0.00							15.00				5.00					5.00			5.00				
S5967	144	0		29	10	S5967_144_0	3	2	Preferred Brand	1	3	010001		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		45.00	90.00	135.00																													45.00	90.00	90.00							135.00				45.00					45.00			45.00				
S5967	144	0		29	10	S5967_144_0	3	3	Non-Preferred Brand	1	3	110000		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		94.00	188.00	282.00																													94.00	188.00	188.00							282.00				94.00					94.00			94.00				
S5967	145	0		29	10	S5967_145_0	3	1	Preferred Generic	1	3	001010		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		5.00	10.00	15.00																													5.00	10.00	0.00							15.00				5.00					5.00			5.00				
S5967	145	0		29	10	S5967_145_0	3	4	Specialty Tier	1	3	010010		1	110000000010000100100101	31													31			31			31		31		31	14					933.24	33																														33							33					33				33			33			
S5967	145	0		29	10	S5967_145_0	3	3	Non-Preferred Brand	1	3	110000		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		94.00	188.00	282.00																													94.00	188.00	188.00							282.00				94.00					94.00			94.00				
S5967	145	0		29	10	S5967_145_0	3	2	Preferred Brand	1	3	010001		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		44.00	88.00	132.00																													44.00	88.00	88.00							132.00				44.00					44.00			44.00				
S5967	146	0		29	10	S5967_146_0	3	4	Specialty Tier	1	3	010010		1	110000000010000100100101	31													31			31			31		31		31	14					933.24	33																														33							33					33				33			33			
S5967	146	0		29	10	S5967_146_0	3	1	Preferred Generic	1	3	001010		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		5.00	10.00	15.00																													5.00	10.00	0.00							15.00				5.00					5.00			5.00				
S5967	146	0		29	10	S5967_146_0	3	2	Preferred Brand	1	3	010001		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		44.00	88.00	132.00																													44.00	88.00	88.00							132.00				44.00					44.00			44.00				
S5967	146	0		29	10	S5967_146_0	3	3	Non-Preferred Brand	1	3	110000		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		95.00	190.00	285.00																													95.00	190.00	190.00							285.00				95.00					95.00			95.00				
S5967	147	0		29	10	S5967_147_0	3	2	Preferred Brand	1	3	010001		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		42.00	84.00	126.00																													42.00	84.00	84.00							126.00				42.00					42.00			42.00				
S5967	147	0		29	10	S5967_147_0	3	3	Non-Preferred Brand	1	3	110000		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		95.00	190.00	285.00																													95.00	190.00	190.00							285.00				95.00					95.00			95.00				
S5967	147	0		29	10	S5967_147_0	3	1	Preferred Generic	1	3	001010		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		5.00	10.00	15.00																													5.00	10.00	0.00							15.00				5.00					5.00			5.00				
S5967	147	0		29	10	S5967_147_0	3	4	Specialty Tier	1	3	010010		1	110000000010000100100101	31													31			31			31		31		31	14					933.24	33																														33							33					33				33			33			
S5967	148	0		29	10	S5967_148_0	3	2	Preferred Brand	1	3	010001		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		45.00	90.00	135.00																													45.00	90.00	90.00							135.00				45.00					45.00			45.00				
S5967	148	0		29	10	S5967_148_0	3	4	Specialty Tier	1	3	010010		1	110000000010000100100101	31													31			31			31		31		31	14					933.24	33																														33							33					33				33			33			
S5967	148	0		29	10	S5967_148_0	3	3	Non-Preferred Brand	1	3	110000		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		95.00	190.00	285.00																													95.00	190.00	190.00							285.00				95.00					95.00			95.00				
S5967	148	0		29	10	S5967_148_0	3	1	Preferred Generic	1	3	001010		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		6.00	12.00	18.00																													6.00	12.00	0.00							18.00				6.00					6.00			6.00				
S5967	149	0		29	10	S5967_149_0	3	3	Non-Preferred Brand	1	3	110000		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		94.00	188.00	282.00																													94.00	188.00	188.00							282.00				94.00					94.00			94.00				
S5967	149	0		29	10	S5967_149_0	3	2	Preferred Brand	1	3	010001		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		41.00	82.00	123.00																													41.00	82.00	82.00							123.00				41.00					41.00			41.00				
S5967	149	0		29	10	S5967_149_0	3	1	Preferred Generic	1	3	001010		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		5.00	10.00	15.00																													5.00	10.00	0.00							15.00				5.00					5.00			5.00				
S5967	149	0		29	10	S5967_149_0	3	4	Specialty Tier	1	3	010010		1	110000000010000100100101	31													31			31			31		31		31	14					933.24	33																														33							33					33				33			33			
S5967	150	0		29	10	S5967_150_0	3	3	Non-Preferred Brand	1	3	110000		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		95.00	190.00	285.00																													95.00	190.00	190.00							285.00				95.00					95.00			95.00				
S5967	150	0		29	10	S5967_150_0	3	4	Specialty Tier	1	3	010010		1	110000000010000100100101	31													31			31			31		31		31	14					933.24	33																														33							33					33				33			33			
S5967	150	0		29	10	S5967_150_0	3	2	Preferred Brand	1	3	010001		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		45.00	90.00	135.00																													45.00	90.00	90.00							135.00				45.00					45.00			45.00				
S5967	150	0		29	10	S5967_150_0	3	1	Preferred Generic	1	3	001010		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		7.00	14.00	21.00																													7.00	14.00	0.00							21.00				7.00					7.00			7.00				
S5967	151	0		29	10	S5967_151_0	3	3	Non-Preferred Brand	1	3	110000		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		92.00	184.00	276.00																													92.00	184.00	184.00							276.00				92.00					92.00			92.00				
S5967	151	0		29	10	S5967_151_0	3	4	Specialty Tier	1	3	010010		1	110000000010000100100101	31													31			31			31		31		31	14					933.24	33																														33							33					33				33			33			
S5967	151	0		29	10	S5967_151_0	3	1	Preferred Generic	1	3	001010		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		6.00	12.00	18.00																													6.00	12.00	0.00							18.00				6.00					6.00			6.00				
S5967	151	0		29	10	S5967_151_0	3	2	Preferred Brand	1	3	010001		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		40.00	80.00	120.00																													40.00	80.00	80.00							120.00				40.00					40.00			40.00				
S5967	152	0		29	10	S5967_152_0	3	3	Non-Preferred Brand	1	3	110000		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		92.00	184.00	276.00																													92.00	184.00	184.00							276.00				92.00					92.00			92.00				
S5967	152	0		29	10	S5967_152_0	3	1	Preferred Generic	1	3	001010		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		6.00	12.00	18.00																													6.00	12.00	0.00							18.00				6.00					6.00			6.00				
S5967	152	0		29	10	S5967_152_0	3	2	Preferred Brand	1	3	010001		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		40.00	80.00	120.00																													40.00	80.00	80.00							120.00				40.00					40.00			40.00				
S5967	152	0		29	10	S5967_152_0	3	4	Specialty Tier	1	3	010010		1	110000000010000100100101	31													31			31			31		31		31	14					933.24	33																														33							33					33				33			33			
S5967	154	0		29	10	S5967_154_0	3	1	Preferred Generic	1	3	001010		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		6.00	12.00	18.00																													6.00	12.00	0.00							18.00				6.00					6.00			6.00				
S5967	154	0		29	10	S5967_154_0	3	3	Non-Preferred Brand	1	3	110000		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		94.00	188.00	282.00																													94.00	188.00	188.00							282.00				94.00					94.00			94.00				
S5967	154	0		29	10	S5967_154_0	3	4	Specialty Tier	1	3	010010		1	110000000010000100100101	31													31			31			31		31		31	14					933.24	33																														33							33					33				33			33			
S5967	154	0		29	10	S5967_154_0	3	2	Preferred Brand	1	3	010001		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		42.00	84.00	126.00																													42.00	84.00	84.00							126.00				42.00					42.00			42.00				
S5967	155	0		29	10	S5967_155_0	3	2	Preferred Brand	1	3	010001		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		41.00	82.00	123.00																													41.00	82.00	82.00							123.00				41.00					41.00			41.00				
S5967	155	0		29	10	S5967_155_0	3	1	Preferred Generic	1	3	001010		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		5.00	10.00	15.00																													5.00	10.00	0.00							15.00				5.00					5.00			5.00				
S5967	155	0		29	10	S5967_155_0	3	3	Non-Preferred Brand	1	3	110000		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		92.00	184.00	276.00																													92.00	184.00	184.00							276.00				92.00					92.00			92.00				
S5967	155	0		29	10	S5967_155_0	3	4	Specialty Tier	1	3	010010		1	110000000010000100100101	31													31			31			31		31		31	14					933.24	33																														33							33					33				33			33			
S5967	156	0		29	10	S5967_156_0	3	1	Preferred Generic	1	3	001010		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		5.00	10.00	15.00																													5.00	10.00	0.00							15.00				5.00					5.00			5.00				
S5967	156	0		29	10	S5967_156_0	3	2	Preferred Brand	1	3	010001		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		42.00	84.00	126.00																													42.00	84.00	84.00							126.00				42.00					42.00			42.00				
S5967	156	0		29	10	S5967_156_0	3	3	Non-Preferred Brand	1	3	110000		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		94.00	188.00	282.00																													94.00	188.00	188.00							282.00				94.00					94.00			94.00				
S5967	156	0		29	10	S5967_156_0	3	4	Specialty Tier	1	3	010010		1	110000000010000100100101	31													31			31			31		31		31	14					933.24	33																														33							33					33				33			33			
S5967	157	0		29	10	S5967_157_0	3	2	Preferred Brand	1	3	010001		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		40.00	80.00	120.00																													40.00	80.00	80.00							120.00				40.00					40.00			40.00				
S5967	157	0		29	10	S5967_157_0	3	4	Specialty Tier	1	3	010010		1	110000000010000100100101	31													31			31			31		31		31	14					933.24	33																														33							33					33				33			33			
S5967	157	0		29	10	S5967_157_0	3	3	Non-Preferred Brand	1	3	110000		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		91.00	182.00	273.00																													91.00	182.00	182.00							273.00				91.00					91.00			91.00				
S5967	157	0		29	10	S5967_157_0	3	1	Preferred Generic	1	3	001010		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		5.00	10.00	15.00																													5.00	10.00	0.00							15.00				5.00					5.00			5.00				
S5967	158	0		29	10	S5967_158_0	3	4	Specialty Tier	1	3	010010		1	110000000010000100100101	31													31			31			31		31		31	14					933.24	33																														33							33					33				33			33			
S5967	158	0		29	10	S5967_158_0	3	3	Non-Preferred Brand	1	3	110000		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		93.00	186.00	279.00																													93.00	186.00	186.00							279.00				93.00					93.00			93.00				
S5967	158	0		29	10	S5967_158_0	3	2	Preferred Brand	1	3	010001		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		43.00	86.00	129.00																													43.00	86.00	86.00							129.00				43.00					43.00			43.00				
S5967	158	0		29	10	S5967_158_0	3	1	Preferred Generic	1	3	001010		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		5.00	10.00	15.00																													5.00	10.00	0.00							15.00				5.00					5.00			5.00				
S5967	159	0		29	10	S5967_159_0	3	3	Non-Preferred Brand	1	3	110000		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		95.00	190.00	285.00																													95.00	190.00	190.00							285.00				95.00					95.00			95.00				
S5967	159	0		29	10	S5967_159_0	3	2	Preferred Brand	1	3	010001		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		42.00	84.00	126.00																													42.00	84.00	84.00							126.00				42.00					42.00			42.00				
S5967	159	0		29	10	S5967_159_0	3	4	Specialty Tier	1	3	010010		1	110000000010000100100101	31													31			31			31		31		31	14					933.24	33																														33							33					33				33			33			
S5967	159	0		29	10	S5967_159_0	3	1	Preferred Generic	1	3	001010		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		7.00	14.00	21.00																													7.00	14.00	0.00							21.00				7.00					7.00			7.00				
S5967	160	0		29	10	S5967_160_0	3	1	Preferred Generic	1	3	001010		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		5.00	10.00	15.00																													5.00	10.00	0.00							15.00				5.00					5.00			5.00				
S5967	160	0		29	10	S5967_160_0	3	2	Preferred Brand	1	3	010001		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		42.00	84.00	126.00																													42.00	84.00	84.00							126.00				42.00					42.00			42.00				
S5967	160	0		29	10	S5967_160_0	3	4	Specialty Tier	1	3	010010		1	110000000010000100100101	31													31			31			31		31		31	14					933.24	33																														33							33					33				33			33			
S5967	160	0		29	10	S5967_160_0	3	3	Non-Preferred Brand	1	3	110000		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		94.00	188.00	282.00																													94.00	188.00	188.00							282.00				94.00					94.00			94.00				
S5967	161	0		29	10	S5967_161_0	3	4	Specialty Tier	1	3	010010		1	110000000010000100100101	31													31			31			31		31		31	14					933.24	33																														33							33					33				33			33			
S5967	161	0		29	10	S5967_161_0	3	3	Non-Preferred Brand	1	3	110000		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		95.00	190.00	285.00																													95.00	190.00	190.00							285.00				95.00					95.00			95.00				
S5967	161	0		29	10	S5967_161_0	3	2	Preferred Brand	1	3	010001		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		42.00	84.00	126.00																													42.00	84.00	84.00							126.00				42.00					42.00			42.00				
S5967	161	0		29	10	S5967_161_0	3	1	Preferred Generic	1	3	001010		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		5.00	10.00	15.00																													5.00	10.00	0.00							15.00				5.00					5.00			5.00				
S5967	162	0		29	10	S5967_162_0	3	1	Preferred Generic	1	3	001010		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		5.00	10.00	15.00																													5.00	10.00	0.00							15.00				5.00					5.00			5.00				
S5967	162	0		29	10	S5967_162_0	3	3	Non-Preferred Brand	1	3	110000		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		95.00	190.00	285.00																													95.00	190.00	190.00							285.00				95.00					95.00			95.00				
S5967	162	0		29	10	S5967_162_0	3	2	Preferred Brand	1	3	010001		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		43.00	86.00	129.00																													43.00	86.00	86.00							129.00				43.00					43.00			43.00				
S5967	162	0		29	10	S5967_162_0	3	4	Specialty Tier	1	3	010010		1	110000000010000100100101	31													31			31			31		31		31	14					933.24	33																														33							33					33				33			33			
S5967	163	0		29	10	S5967_163_0	3	4	Specialty Tier	1	3	010010		1	110000000010000100100101	31													31			31			31		31		31	14					933.24	33																														33							33					33				33			33			
S5967	163	0		29	10	S5967_163_0	3	3	Non-Preferred Brand	1	3	110000		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		94.00	188.00	282.00																													94.00	188.00	188.00							282.00				94.00					94.00			94.00				
S5967	163	0		29	10	S5967_163_0	3	1	Preferred Generic	1	3	001010		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		7.00	14.00	21.00																													7.00	14.00	0.00							21.00				7.00					7.00			7.00				
S5967	163	0		29	10	S5967_163_0	3	2	Preferred Brand	1	3	010001		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		42.00	84.00	126.00																													42.00	84.00	84.00							126.00				42.00					42.00			42.00				
S5967	164	0		29	10	S5967_164_0	3	3	Non-Preferred Brand	1	3	110000		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		95.00	190.00	285.00																													95.00	190.00	190.00							285.00				95.00					95.00			95.00				
S5967	164	0		29	10	S5967_164_0	3	2	Preferred Brand	1	3	010001		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		43.00	86.00	129.00																													43.00	86.00	86.00							129.00				43.00					43.00			43.00				
S5967	164	0		29	10	S5967_164_0	3	1	Preferred Generic	1	3	001010		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		6.00	12.00	18.00																													6.00	12.00	0.00							18.00				6.00					6.00			6.00				
S5967	164	0		29	10	S5967_164_0	3	4	Specialty Tier	1	3	010010		1	110000000010000100100101	31													31			31			31		31		31	14					933.24	33																														33							33					33				33			33			
S5967	165	0		29	10	S5967_165_0	3	2	Preferred Brand	1	3	010001		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		41.00	82.00	123.00																													41.00	82.00	82.00							123.00				41.00					41.00			41.00				
S5967	165	0		29	10	S5967_165_0	3	3	Non-Preferred Brand	1	3	110000		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		92.00	184.00	276.00																													92.00	184.00	184.00							276.00				92.00					92.00			92.00				
S5967	165	0		29	10	S5967_165_0	3	4	Specialty Tier	1	3	010010		1	110000000010000100100101	31													31			31			31		31		31	14					933.24	33																														33							33					33				33			33			
S5967	165	0		29	10	S5967_165_0	3	1	Preferred Generic	1	3	001010		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		8.00	16.00	24.00																													8.00	16.00	0.00							24.00				8.00					8.00			8.00				
S5967	166	0		29	10	S5967_166_0	3	4	Specialty Tier	1	3	010010		1	110000000010000100100101	31													31			31			31		31		31	14					933.24	33																														33							33					33				33			33			
S5967	166	0		29	10	S5967_166_0	3	1	Preferred Generic	1	3	001010		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		7.00	14.00	21.00																													7.00	14.00	0.00							21.00				7.00					7.00			7.00				
S5967	166	0		29	10	S5967_166_0	3	3	Non-Preferred Brand	1	3	110000		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		91.00	182.00	273.00																													91.00	182.00	182.00							273.00				91.00					91.00			91.00				
S5967	166	0		29	10	S5967_166_0	3	2	Preferred Brand	1	3	010001		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		41.00	82.00	123.00																													41.00	82.00	82.00							123.00				41.00					41.00			41.00				
S5967	167	0		29	10	S5967_167_0	3	3	Non-Preferred Brand	1	3	110000		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		93.00	186.00	279.00																													93.00	186.00	186.00							279.00				93.00					93.00			93.00				
S5967	167	0		29	10	S5967_167_0	3	2	Preferred Brand	1	3	010001		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		41.00	82.00	123.00																													41.00	82.00	82.00							123.00				41.00					41.00			41.00				
S5967	167	0		29	10	S5967_167_0	3	1	Preferred Generic	1	3	001010		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		6.00	12.00	18.00																													6.00	12.00	0.00							18.00				6.00					6.00			6.00				
S5967	167	0		29	10	S5967_167_0	3	4	Specialty Tier	1	3	010010		1	110000000010000100100101	31													31			31			31		31		31	14					933.24	33																														33							33					33				33			33			
S5967	168	0		29	10	S5967_168_0	3	2	Preferred Brand	1	3	010001		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		41.00	82.00	123.00																													41.00	82.00	82.00							123.00				41.00					41.00			41.00				
S5967	168	0		29	10	S5967_168_0	3	1	Preferred Generic	1	3	001010		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		6.00	12.00	18.00																													6.00	12.00	0.00							18.00				6.00					6.00			6.00				
S5967	168	0		29	10	S5967_168_0	3	3	Non-Preferred Brand	1	3	110000		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		95.00	190.00	285.00																													95.00	190.00	190.00							285.00				95.00					95.00			95.00				
S5967	168	0		29	10	S5967_168_0	3	4	Specialty Tier	1	3	010010		1	110000000010000100100101	31													31			31			31		31		31	14					933.24	33																														33							33					33				33			33			
S5967	169	0		29	10	S5967_169_0	3	1	Preferred Generic	1	3	001010		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		6.00	12.00	18.00																													6.00	12.00	0.00							18.00				6.00					6.00			6.00				
S5967	169	0		29	10	S5967_169_0	3	2	Preferred Brand	1	3	010001		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		45.00	90.00	135.00																													45.00	90.00	90.00							135.00				45.00					45.00			45.00				
S5967	169	0		29	10	S5967_169_0	3	3	Non-Preferred Brand	1	3	110000		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		95.00	190.00	285.00																													95.00	190.00	190.00							285.00				95.00					95.00			95.00				
S5967	169	0		29	10	S5967_169_0	3	4	Specialty Tier	1	3	010010		1	110000000010000100100101	31													31			31			31		31		31	14					933.24	33																														33							33					33				33			33			
S5967	170	0		29	10	S5967_170_0	3	1	Preferred Generic	1	3	001010		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		6.00	12.00	18.00																													6.00	12.00	0.00							18.00				6.00					6.00			6.00				
S5967	170	0		29	10	S5967_170_0	3	4	Specialty Tier	1	3	010010		1	110000000010000100100101	31													31			31			31		31		31	14					933.24	33																														33							33					33				33			33			
S5967	170	0		29	10	S5967_170_0	3	2	Preferred Brand	1	3	010001		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		43.00	86.00	129.00																													43.00	86.00	86.00							129.00				43.00					43.00			43.00				
S5967	170	0		29	10	S5967_170_0	3	3	Non-Preferred Brand	1	3	110000		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		95.00	190.00	285.00																													95.00	190.00	190.00							285.00				95.00					95.00			95.00				
S5967	171	0		29	10	S5967_171_0	3	3	Non-Preferred Brand	1	3	110000		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		82.00	164.00	246.00																													82.00	164.00	164.00							246.00				82.00					82.00			82.00				
S5967	171	0		29	10	S5967_171_0	3	2	Preferred Brand	1	3	010001		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		35.00	70.00	105.00																													35.00	70.00	70.00							105.00				35.00					35.00			35.00				
S5967	171	0		29	10	S5967_171_0	3	1	Preferred Generic	1	3	001010		2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		8.00	16.00	24.00																													8.00	16.00	0.00							24.00				8.00					8.00			8.00				
S5967	171	0		29	10	S5967_171_0	3	4	Specialty Tier	1	3	010010		1	110000000010000100100101	31													31			31			31		31		31	14					933.24	33																														33							33					33				33			33			
S5967	173	0		29	10	S5967_173_0	6	1	Preferred Generic	3	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		2.00	4.00	6.00																													2.00	4.00	0.00							6.00				2.00					2.00			2.00		1		
S5967	173	0		29	10	S5967_173_0	6	5	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
S5967	173	0		29	10	S5967_173_0	6	4	Non-Preferred Brand	1	4	100000	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					93.96	50	50	50																												50	50	34							50			50							50			
S5967	173	0		29	10	S5967_173_0	6	2	Non-Preferred Generic	1	4	000110	1	1	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14					18.56	25	25	25																												25	25	17							25			25				25			25			
S5967	173	0		29	10	S5967_173_0	6	1	Preferred Generic	1	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
S5967	173	0		29	10	S5967_173_0	6	3	Preferred Brand	1	4	000001	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					33.10	25	25	25																												25	25	17							25			25							25			
S5967	174	0		29	10	S5967_174_0	3	1	Preferred Generic	1	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
S5967	174	0		29	10	S5967_174_0	3	2	Non-Preferred Generic	1	4	000110	1	1	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14					18.56	25	25	25																												25	25	17							25			25				25			25			
S5967	174	0		29	10	S5967_174_0	3	3	Preferred Brand	1	4	000001	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					33.10	25	25	25																												25	25	17							25			25							25			
S5967	174	0		29	10	S5967_174_0	3	4	Non-Preferred Brand	1	4	100000	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					93.96	50	50	50																												50	50	34							50			50							50			
S5967	174	0		29	10	S5967_174_0	3	5	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
S5967	174	0		29	10	S5967_174_0	3	1	Preferred Generic	3	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		2.00	4.00	6.00																													2.00	4.00	0.00							6.00				2.00					2.00			2.00		1		
S5967	175	0		29	10	S5967_175_0	3	5	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
S5967	175	0		29	10	S5967_175_0	3	1	Preferred Generic	3	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		2.00	4.00	6.00																													2.00	4.00	0.00							6.00				2.00					2.00			2.00		1		
S5967	175	0		29	10	S5967_175_0	3	2	Non-Preferred Generic	1	4	000110	1	1	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14					18.56	25	25	25																												25	25	17							25			25				25			25			
S5967	175	0		29	10	S5967_175_0	3	1	Preferred Generic	1	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
S5967	175	0		29	10	S5967_175_0	3	3	Preferred Brand	1	4	000001	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					33.10	25	25	25																												25	25	17							25			25							25			
S5967	175	0		29	10	S5967_175_0	3	4	Non-Preferred Brand	1	4	100000	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					93.96	50	50	50																												50	50	34							50			50							50			
S5967	176	0		29	10	S5967_176_0	3	1	Preferred Generic	1	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
S5967	176	0		29	10	S5967_176_0	3	2	Non-Preferred Generic	1	4	000110	1	1	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14					18.56	25	25	25																												25	25	17							25			25				25			25			
S5967	176	0		29	10	S5967_176_0	3	3	Preferred Brand	1	4	000001	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					33.10	25	25	25																												25	25	17							25			25							25			
S5967	176	0		29	10	S5967_176_0	3	5	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
S5967	176	0		29	10	S5967_176_0	3	1	Preferred Generic	3	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		2.00	4.00	6.00																													2.00	4.00	0.00							6.00				2.00					2.00			2.00		1		
S5967	176	0		29	10	S5967_176_0	3	4	Non-Preferred Brand	1	4	100000	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					93.96	50	50	50																												50	50	34							50			50							50			
S5967	177	0		29	10	S5967_177_0	3	1	Preferred Generic	1	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
S5967	177	0		29	10	S5967_177_0	3	1	Preferred Generic	3	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		2.00	4.00	6.00																													2.00	4.00	0.00							6.00				2.00					2.00			2.00		1		
S5967	177	0		29	10	S5967_177_0	3	5	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
S5967	177	0		29	10	S5967_177_0	3	4	Non-Preferred Brand	1	4	100000	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					93.96	50	50	50																												50	50	34							50			50							50			
S5967	177	0		29	10	S5967_177_0	3	3	Preferred Brand	1	4	000001	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					33.10	25	25	25																												25	25	17							25			25							25			
S5967	177	0		29	10	S5967_177_0	3	2	Non-Preferred Generic	1	4	000110	1	1	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14					18.56	25	25	25																												25	25	17							25			25				25			25			
S5967	178	0		29	10	S5967_178_0	3	2	Non-Preferred Generic	1	4	000110	1	1	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14					18.56	25	25	25																												25	25	17							25			25				25			25			
S5967	178	0		29	10	S5967_178_0	3	4	Non-Preferred Brand	1	4	100000	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					93.96	50	50	50																												50	50	34							50			50							50			
S5967	178	0		29	10	S5967_178_0	3	1	Preferred Generic	3	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		2.00	4.00	6.00																													2.00	4.00	0.00							6.00				2.00					2.00			2.00		1		
S5967	178	0		29	10	S5967_178_0	3	5	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
S5967	178	0		29	10	S5967_178_0	3	1	Preferred Generic	1	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
S5967	178	0		29	10	S5967_178_0	3	3	Preferred Brand	1	4	000001	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					33.10	25	25	25																												25	25	17							25			25							25			
S5967	179	0		29	10	S5967_179_0	3	5	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
S5967	179	0		29	10	S5967_179_0	3	1	Preferred Generic	3	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		2.00	4.00	6.00																													2.00	4.00	0.00							6.00				2.00					2.00			2.00		1		
S5967	179	0		29	10	S5967_179_0	3	2	Non-Preferred Generic	1	4	000110	1	1	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14					18.56	25	25	25																												25	25	17							25			25				25			25			
S5967	179	0		29	10	S5967_179_0	3	3	Preferred Brand	1	4	000001	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					33.10	25	25	25																												25	25	17							25			25							25			
S5967	179	0		29	10	S5967_179_0	3	4	Non-Preferred Brand	1	4	100000	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					93.96	50	50	50																												50	50	34							50			50							50			
S5967	179	0		29	10	S5967_179_0	3	1	Preferred Generic	1	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
S5967	180	0		29	10	S5967_180_0	3	4	Non-Preferred Brand	1	4	100000	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					93.96	50	50	50																												50	50	34							50			50							50			
S5967	180	0		29	10	S5967_180_0	3	5	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
S5967	180	0		29	10	S5967_180_0	3	3	Preferred Brand	1	4	000001	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					33.10	25	25	25																												25	25	17							25			25							25			
S5967	180	0		29	10	S5967_180_0	3	2	Non-Preferred Generic	1	4	000110	1	1	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14					18.56	25	25	25																												25	25	17							25			25				25			25			
S5967	180	0		29	10	S5967_180_0	3	1	Preferred Generic	1	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
S5967	180	0		29	10	S5967_180_0	3	1	Preferred Generic	3	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		2.00	4.00	6.00																													2.00	4.00	0.00							6.00				2.00					2.00			2.00		1		
S5967	181	0		29	10	S5967_181_0	3	1	Preferred Generic	1	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
S5967	181	0		29	10	S5967_181_0	3	2	Non-Preferred Generic	1	4	000110	1	1	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14					18.56	25	25	25																												25	25	17							25			25				25			25			
S5967	181	0		29	10	S5967_181_0	3	3	Preferred Brand	1	4	000001	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					33.10	25	25	25																												25	25	17							25			25							25			
S5967	181	0		29	10	S5967_181_0	3	4	Non-Preferred Brand	1	4	100000	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					93.96	50	50	50																												50	50	34							50			50							50			
S5967	181	0		29	10	S5967_181_0	3	5	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
S5967	181	0		29	10	S5967_181_0	3	1	Preferred Generic	3	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		2.00	4.00	6.00																													2.00	4.00	0.00							6.00				2.00					2.00			2.00		1		
S5967	182	0		29	10	S5967_182_0	3	2	Non-Preferred Generic	1	4	000110	1	1	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14					18.56	25	25	25																												25	25	17							25			25				25			25			
S5967	182	0		29	10	S5967_182_0	3	1	Preferred Generic	1	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
S5967	182	0		29	10	S5967_182_0	3	3	Preferred Brand	1	4	000001	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					33.10	25	25	25																												25	25	17							25			25							25			
S5967	182	0		29	10	S5967_182_0	3	1	Preferred Generic	3	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		2.00	4.00	6.00																													2.00	4.00	0.00							6.00				2.00					2.00			2.00		1		
S5967	182	0		29	10	S5967_182_0	3	5	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
S5967	182	0		29	10	S5967_182_0	3	4	Non-Preferred Brand	1	4	100000	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					93.96	50	50	50																												50	50	34							50			50							50			
S5967	183	0		29	10	S5967_183_0	3	1	Preferred Generic	1	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
S5967	183	0		29	10	S5967_183_0	3	2	Non-Preferred Generic	1	4	000110	1	1	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14					18.56	25	25	25																												25	25	17							25			25				25			25			
S5967	183	0		29	10	S5967_183_0	3	3	Preferred Brand	1	4	000001	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					33.10	25	25	25																												25	25	17							25			25							25			
S5967	183	0		29	10	S5967_183_0	3	4	Non-Preferred Brand	1	4	100000	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					93.96	50	50	50																												50	50	34							50			50							50			
S5967	183	0		29	10	S5967_183_0	3	5	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
S5967	183	0		29	10	S5967_183_0	3	1	Preferred Generic	3	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		2.00	4.00	6.00																													2.00	4.00	0.00							6.00				2.00					2.00			2.00		1		
S5967	184	0		29	10	S5967_184_0	3	5	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
S5967	184	0		29	10	S5967_184_0	3	4	Non-Preferred Brand	1	4	100000	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					93.96	50	50	50																												50	50	34							50			50							50			
S5967	184	0		29	10	S5967_184_0	3	1	Preferred Generic	1	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
S5967	184	0		29	10	S5967_184_0	3	2	Non-Preferred Generic	1	4	000110	1	1	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14					18.56	25	25	25																												25	25	17							25			25				25			25			
S5967	184	0		29	10	S5967_184_0	3	3	Preferred Brand	1	4	000001	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					33.10	25	25	25																												25	25	17							25			25							25			
S5967	184	0		29	10	S5967_184_0	3	1	Preferred Generic	3	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		2.00	4.00	6.00																													2.00	4.00	0.00							6.00				2.00					2.00			2.00		1		
S5967	185	0		29	10	S5967_185_0	3	5	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
S5967	185	0		29	10	S5967_185_0	3	4	Non-Preferred Brand	1	4	100000	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					93.96	50	50	50																												50	50	34							50			50							50			
S5967	185	0		29	10	S5967_185_0	3	3	Preferred Brand	1	4	000001	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					33.10	25	25	25																												25	25	17							25			25							25			
S5967	185	0		29	10	S5967_185_0	3	2	Non-Preferred Generic	1	4	000110	1	1	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14					18.56	25	25	25																												25	25	17							25			25				25			25			
S5967	185	0		29	10	S5967_185_0	3	1	Preferred Generic	1	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
S5967	185	0		29	10	S5967_185_0	3	1	Preferred Generic	3	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		2.00	4.00	6.00																													2.00	4.00	0.00							6.00				2.00					2.00			2.00		1		
S5967	186	0		29	10	S5967_186_0	3	3	Preferred Brand	1	4	000001	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					33.10	25	25	25																												25	25	17							25			25							25			
S5967	186	0		29	10	S5967_186_0	3	2	Non-Preferred Generic	1	4	000110	1	1	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14					18.56	25	25	25																												25	25	17							25			25				25			25			
S5967	186	0		29	10	S5967_186_0	3	1	Preferred Generic	1	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
S5967	186	0		29	10	S5967_186_0	3	4	Non-Preferred Brand	1	4	100000	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					93.96	50	50	50																												50	50	34							50			50							50			
S5967	186	0		29	10	S5967_186_0	3	5	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
S5967	186	0		29	10	S5967_186_0	3	1	Preferred Generic	3	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		2.00	4.00	6.00																													2.00	4.00	0.00							6.00				2.00					2.00			2.00		1		
S5967	187	0		29	10	S5967_187_0	3	1	Preferred Generic	3	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		2.00	4.00	6.00																													2.00	4.00	0.00							6.00				2.00					2.00			2.00		1		
S5967	187	0		29	10	S5967_187_0	3	1	Preferred Generic	1	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
S5967	187	0		29	10	S5967_187_0	3	2	Non-Preferred Generic	1	4	000110	1	1	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14					18.56	25	25	25																												25	25	17							25			25				25			25			
S5967	187	0		29	10	S5967_187_0	3	5	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
S5967	187	0		29	10	S5967_187_0	3	3	Preferred Brand	1	4	000001	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					33.10	25	25	25																												25	25	17							25			25							25			
S5967	187	0		29	10	S5967_187_0	3	4	Non-Preferred Brand	1	4	100000	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					93.96	50	50	50																												50	50	34							50			50							50			
S5967	188	0		29	10	S5967_188_0	3	1	Preferred Generic	3	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		2.00	4.00	6.00																													2.00	4.00	0.00							6.00				2.00					2.00			2.00		1		
S5967	188	0		29	10	S5967_188_0	3	4	Non-Preferred Brand	1	4	100000	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					93.96	50	50	50																												50	50	34							50			50							50			
S5967	188	0		29	10	S5967_188_0	3	1	Preferred Generic	1	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
S5967	188	0		29	10	S5967_188_0	3	2	Non-Preferred Generic	1	4	000110	1	1	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14					18.56	25	25	25																												25	25	17							25			25				25			25			
S5967	188	0		29	10	S5967_188_0	3	3	Preferred Brand	1	4	000001	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					33.10	25	25	25																												25	25	17							25			25							25			
S5967	188	0		29	10	S5967_188_0	3	5	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
S5967	189	0		29	10	S5967_189_0	3	3	Preferred Brand	1	4	000001	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					33.10	25	25	25																												25	25	17							25			25							25			
S5967	189	0		29	10	S5967_189_0	3	2	Non-Preferred Generic	1	4	000110	1	1	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14					18.56	25	25	25																												25	25	17							25			25				25			25			
S5967	189	0		29	10	S5967_189_0	3	1	Preferred Generic	1	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
S5967	189	0		29	10	S5967_189_0	3	4	Non-Preferred Brand	1	4	100000	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					93.96	50	50	50																												50	50	34							50			50							50			
S5967	189	0		29	10	S5967_189_0	3	5	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
S5967	189	0		29	10	S5967_189_0	3	1	Preferred Generic	3	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		2.00	4.00	6.00																													2.00	4.00	0.00							6.00				2.00					2.00			2.00		1		
S5967	190	0		29	10	S5967_190_0	3	4	Non-Preferred Brand	1	4	100000	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					93.96	50	50	50																												50	50	34							50			50							50			
S5967	190	0		29	10	S5967_190_0	3	5	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
S5967	190	0		29	10	S5967_190_0	3	3	Preferred Brand	1	4	000001	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					33.10	25	25	25																												25	25	17							25			25							25			
S5967	190	0		29	10	S5967_190_0	3	2	Non-Preferred Generic	1	4	000110	1	1	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14					18.56	25	25	25																												25	25	17							25			25				25			25			
S5967	190	0		29	10	S5967_190_0	3	1	Preferred Generic	1	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
S5967	190	0		29	10	S5967_190_0	3	1	Preferred Generic	3	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		2.00	4.00	6.00																													2.00	4.00	0.00							6.00				2.00					2.00			2.00		1		
S5967	191	0		29	10	S5967_191_0	3	1	Preferred Generic	1	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
S5967	191	0		29	10	S5967_191_0	3	2	Non-Preferred Generic	1	4	000110	1	1	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14					18.56	25	25	25																												25	25	17							25			25				25			25			
S5967	191	0		29	10	S5967_191_0	3	3	Preferred Brand	1	4	000001	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					33.10	25	25	25																												25	25	17							25			25							25			
S5967	191	0		29	10	S5967_191_0	3	4	Non-Preferred Brand	1	4	100000	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					93.96	50	50	50																												50	50	34							50			50							50			
S5967	191	0		29	10	S5967_191_0	3	5	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
S5967	191	0		29	10	S5967_191_0	3	1	Preferred Generic	3	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		2.00	4.00	6.00																													2.00	4.00	0.00							6.00				2.00					2.00			2.00		1		
S5967	192	0		29	10	S5967_192_0	3	2	Non-Preferred Generic	1	4	000110	1	1	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14					18.56	25	25	25																												25	25	17							25			25				25			25			
S5967	192	0		29	10	S5967_192_0	3	1	Preferred Generic	1	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
S5967	192	0		29	10	S5967_192_0	3	3	Preferred Brand	1	4	000001	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					33.10	25	25	25																												25	25	17							25			25							25			
S5967	192	0		29	10	S5967_192_0	3	1	Preferred Generic	3	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		2.00	4.00	6.00																													2.00	4.00	0.00							6.00				2.00					2.00			2.00		1		
S5967	192	0		29	10	S5967_192_0	3	5	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
S5967	192	0		29	10	S5967_192_0	3	4	Non-Preferred Brand	1	4	100000	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					93.96	50	50	50																												50	50	34							50			50							50			
S5967	193	0		29	10	S5967_193_0	3	1	Preferred Generic	1	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
S5967	193	0		29	10	S5967_193_0	3	2	Non-Preferred Generic	1	4	000110	1	1	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14					18.56	25	25	25																												25	25	17							25			25				25			25			
S5967	193	0		29	10	S5967_193_0	3	3	Preferred Brand	1	4	000001	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					33.10	25	25	25																												25	25	17							25			25							25			
S5967	193	0		29	10	S5967_193_0	3	4	Non-Preferred Brand	1	4	100000	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					93.96	50	50	50																												50	50	34							50			50							50			
S5967	193	0		29	10	S5967_193_0	3	5	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
S5967	193	0		29	10	S5967_193_0	3	1	Preferred Generic	3	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		2.00	4.00	6.00																													2.00	4.00	0.00							6.00				2.00					2.00			2.00		1		
S5967	194	0		29	10	S5967_194_0	3	5	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
S5967	194	0		29	10	S5967_194_0	3	4	Non-Preferred Brand	1	4	100000	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					93.96	50	50	50																												50	50	34							50			50							50			
S5967	194	0		29	10	S5967_194_0	3	1	Preferred Generic	1	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
S5967	194	0		29	10	S5967_194_0	3	2	Non-Preferred Generic	1	4	000110	1	1	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14					18.56	25	25	25																												25	25	17							25			25				25			25			
S5967	194	0		29	10	S5967_194_0	3	3	Preferred Brand	1	4	000001	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					33.10	25	25	25																												25	25	17							25			25							25			
S5967	194	0		29	10	S5967_194_0	3	1	Preferred Generic	3	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		2.00	4.00	6.00																													2.00	4.00	0.00							6.00				2.00					2.00			2.00		1		
S5967	195	0		29	10	S5967_195_0	3	5	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
S5967	195	0		29	10	S5967_195_0	3	4	Non-Preferred Brand	1	4	100000	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					93.96	50	50	50																												50	50	34							50			50							50			
S5967	195	0		29	10	S5967_195_0	3	3	Preferred Brand	1	4	000001	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					33.10	25	25	25																												25	25	17							25			25							25			
S5967	195	0		29	10	S5967_195_0	3	2	Non-Preferred Generic	1	4	000110	1	1	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14					18.56	25	25	25																												25	25	17							25			25				25			25			
S5967	195	0		29	10	S5967_195_0	3	1	Preferred Generic	1	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
S5967	195	0		29	10	S5967_195_0	3	1	Preferred Generic	3	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		2.00	4.00	6.00																													2.00	4.00	0.00							6.00				2.00					2.00			2.00		1		
S5967	196	0		29	10	S5967_196_0	3	1	Preferred Generic	1	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
S5967	196	0		29	10	S5967_196_0	3	2	Non-Preferred Generic	1	4	000110	1	1	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14					18.56	25	25	25																												25	25	17							25			25				25			25			
S5967	196	0		29	10	S5967_196_0	3	3	Preferred Brand	1	4	000001	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					33.10	25	25	25																												25	25	17							25			25							25			
S5967	196	0		29	10	S5967_196_0	3	4	Non-Preferred Brand	1	4	100000	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					93.96	50	50	50																												50	50	34							50			50							50			
S5967	196	0		29	10	S5967_196_0	3	5	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
S5967	196	0		29	10	S5967_196_0	3	1	Preferred Generic	3	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		2.00	4.00	6.00																													2.00	4.00	0.00							6.00				2.00					2.00			2.00		1		
S5967	197	0		29	10	S5967_197_0	3	5	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
S5967	197	0		29	10	S5967_197_0	3	4	Non-Preferred Brand	1	4	100000	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					93.96	50	50	50																												50	50	34							50			50							50			
S5967	197	0		29	10	S5967_197_0	3	3	Preferred Brand	1	4	000001	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					33.10	25	25	25																												25	25	17							25			25							25			
S5967	197	0		29	10	S5967_197_0	3	2	Non-Preferred Generic	1	4	000110	1	1	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14					18.56	25	25	25																												25	25	17							25			25				25			25			
S5967	197	0		29	10	S5967_197_0	3	1	Preferred Generic	1	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
S5967	197	0		29	10	S5967_197_0	3	1	Preferred Generic	3	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		2.00	4.00	6.00																													2.00	4.00	0.00							6.00				2.00					2.00			2.00		1		
S5967	198	0		29	10	S5967_198_0	3	1	Preferred Generic	3	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		2.00	4.00	6.00																													2.00	4.00	0.00							6.00				2.00					2.00			2.00		1		
S5967	198	0		29	10	S5967_198_0	3	5	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
S5967	198	0		29	10	S5967_198_0	3	4	Non-Preferred Brand	1	4	100000	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					93.96	50	50	50																												50	50	34							50			50							50			
S5967	198	0		29	10	S5967_198_0	3	3	Preferred Brand	1	4	000001	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					33.10	25	25	25																												25	25	17							25			25							25			
S5967	198	0		29	10	S5967_198_0	3	1	Preferred Generic	1	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
S5967	198	0		29	10	S5967_198_0	3	2	Non-Preferred Generic	1	4	000110	1	1	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14					18.56	25	25	25																												25	25	17							25			25				25			25			
S5967	199	0		29	10	S5967_199_0	3	5	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
S5967	199	0		29	10	S5967_199_0	3	4	Non-Preferred Brand	1	4	100000	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					93.96	50	50	50																												50	50	34							50			50							50			
S5967	199	0		29	10	S5967_199_0	3	3	Preferred Brand	1	4	000001	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					33.10	25	25	25																												25	25	17							25			25							25			
S5967	199	0		29	10	S5967_199_0	3	2	Non-Preferred Generic	1	4	000110	1	1	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14					18.56	25	25	25																												25	25	17							25			25				25			25			
S5967	199	0		29	10	S5967_199_0	3	1	Preferred Generic	1	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
S5967	199	0		29	10	S5967_199_0	3	1	Preferred Generic	3	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		2.00	4.00	6.00																													2.00	4.00	0.00							6.00				2.00					2.00			2.00		1		
S5967	200	0		29	10	S5967_200_0	3	1	Preferred Generic	1	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
S5967	200	0		29	10	S5967_200_0	3	2	Non-Preferred Generic	1	4	000110	1	1	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14					18.56	25	25	25																												25	25	17							25			25				25			25			
S5967	200	0		29	10	S5967_200_0	3	3	Preferred Brand	1	4	000001	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					33.10	25	25	25																												25	25	17							25			25							25			
S5967	200	0		29	10	S5967_200_0	3	1	Preferred Generic	3	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		2.00	4.00	6.00																													2.00	4.00	0.00							6.00				2.00					2.00			2.00		1		
S5967	200	0		29	10	S5967_200_0	3	5	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
S5967	200	0		29	10	S5967_200_0	3	4	Non-Preferred Brand	1	4	100000	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					93.96	50	50	50																												50	50	34							50			50							50			
S5967	201	0		29	10	S5967_201_0	3	1	Preferred Generic	3	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		2.00	4.00	6.00																													2.00	4.00	0.00							6.00				2.00					2.00			2.00		1		
S5967	201	0		29	10	S5967_201_0	3	5	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
S5967	201	0		29	10	S5967_201_0	3	3	Preferred Brand	1	4	000001	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					33.10	25	25	25																												25	25	17							25			25							25			
S5967	201	0		29	10	S5967_201_0	3	4	Non-Preferred Brand	1	4	100000	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					93.96	50	50	50																												50	50	34							50			50							50			
S5967	201	0		29	10	S5967_201_0	3	2	Non-Preferred Generic	1	4	000110	1	1	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14					18.56	25	25	25																												25	25	17							25			25				25			25			
S5967	201	0		29	10	S5967_201_0	3	1	Preferred Generic	1	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
S5967	202	0		29	10	S5967_202_0	3	3	Preferred Brand	1	4	000001	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					33.10	25	25	25																												25	25	17							25			25							25			
S5967	202	0		29	10	S5967_202_0	3	2	Non-Preferred Generic	1	4	000110	1	1	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14					18.56	25	25	25																												25	25	17							25			25				25			25			
S5967	202	0		29	10	S5967_202_0	3	1	Preferred Generic	1	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
S5967	202	0		29	10	S5967_202_0	3	1	Preferred Generic	3	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		2.00	4.00	6.00																													2.00	4.00	0.00							6.00				2.00					2.00			2.00		1		
S5967	202	0		29	10	S5967_202_0	3	5	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
S5967	202	0		29	10	S5967_202_0	3	4	Non-Preferred Brand	1	4	100000	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					93.96	50	50	50																												50	50	34							50			50							50			
S5967	203	0		29	10	S5967_203_0	3	1	Preferred Generic	1	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
S5967	203	0		29	10	S5967_203_0	3	1	Preferred Generic	3	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		2.00	4.00	6.00																													2.00	4.00	0.00							6.00				2.00					2.00			2.00		1		
S5967	203	0		29	10	S5967_203_0	3	3	Preferred Brand	1	4	000001	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					33.10	25	25	25																												25	25	17							25			25							25			
S5967	203	0		29	10	S5967_203_0	3	2	Non-Preferred Generic	1	4	000110	1	1	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14					18.56	25	25	25																												25	25	17							25			25				25			25			
S5967	203	0		29	10	S5967_203_0	3	5	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
S5967	203	0		29	10	S5967_203_0	3	4	Non-Preferred Brand	1	4	100000	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					93.96	50	50	50																												50	50	34							50			50							50			
S5967	204	0		29	10	S5967_204_0	3	1	Preferred Generic	1	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
S5967	204	0		29	10	S5967_204_0	3	2	Non-Preferred Generic	1	4	000110	1	1	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14					18.56	25	25	25																												25	25	17							25			25				25			25			
S5967	204	0		29	10	S5967_204_0	3	3	Preferred Brand	1	4	000001	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					33.10	25	25	25																												25	25	17							25			25							25			
S5967	204	0		29	10	S5967_204_0	3	4	Non-Preferred Brand	1	4	100000	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					93.96	50	50	50																												50	50	34							50			50							50			
S5967	204	0		29	10	S5967_204_0	3	5	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
S5967	204	0		29	10	S5967_204_0	3	1	Preferred Generic	3	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		2.00	4.00	6.00																													2.00	4.00	0.00							6.00				2.00					2.00			2.00		1		
S5967	205	0		29	10	S5967_205_0	3	1	Preferred Generic	1	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		0.00	0.00	0.00																													0.00	0.00	0.00							0.00				0.00					0.00			0.00				
S5967	205	0		29	10	S5967_205_0	3	2	Non-Preferred Generic	1	4	000110	1	1	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14					18.56	25	25	25																												25	25	17							25			25				25			25			
S5967	205	0		29	10	S5967_205_0	3	3	Preferred Brand	1	4	000001	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					33.10	25	25	25																												25	25	17							25			25							25			
S5967	205	0		29	10	S5967_205_0	3	1	Preferred Generic	3	4	001010	1	2	111100000010000111001101	31	62	93							1				31	62	93			93	31		31		31	14		2.00	4.00	6.00																													2.00	4.00	0.00							6.00				2.00					2.00			2.00		1		
S5967	205	0		29	10	S5967_205_0	3	4	Non-Preferred Brand	1	4	100000	1	1	111100000010000111001001	31	62	93							1				31	62	93			93	31				31	14					93.96	50	50	50																												50	50	34							50			50							50			
S5967	205	0		29	10	S5967_205_0	3	5	Specialty Tier	1	4	000010	1	1	110000000010000100100001	31													31			31			31				31	14					933.24	33																														33							33					33							33			
S5983	004	0		29	10	S5983_004_0	3	1	Preferred Generic	1	2	001010		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		4.00		12.00																															8.00							12.00				4.00					4.00			4.00				
S5983	004	0		29	10	S5983_004_0	3	2	Non-Preferred Generic	1	2	000110		2	110100000010000001001111	31		90							2						90			90	31		31	7	31	7		6.00		18.00																															12.00							18.00				6.00					6.00			6.00				
S5983	004	0		29	10	S5983_004_0	3	5	Specialty Tier	1	2	010010		1	110000000010000100100111	31													31			31			31		31	7	31	7					266.00	25																														25							25					25				25			25			
S5983	004	0		29	10	S5983_004_0	3	4	Non-Preferred Brand	1	2	110000		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					103.00	45		45																														45							45			45				45			45			
S5983	004	0		29	10	S5983_004_0	3	3	Preferred Brand	1	2	010001		1	110100000010000001001111	31		90							2						90			90	31		31	7	31	7					41.00	25		25																														25							25			25				25			25			
S5993	001	0		29	10	S5993_001_0	3	4	Non-Preferred Brand	1	2	100000		2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		80.00	160.00	240.00																						80.00	160.00	240.00																		80.00								80.00				
S5993	001	0		29	10	S5993_001_0	3	3	Preferred Brand	1	2	000001		2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		40.00	80.00	120.00																						40.00	80.00	120.00																		40.00								40.00				
S5993	001	0		29	10	S5993_001_0	3	2	Non-Preferred Generic	1	2	000100		2	011100000010111000000100	30	60	90							1	30	60	90							30		31					6.00	12.00	18.00																						3.00	6.00	9.00																		6.00					6.00							
S5993	001	0		29	10	S5993_001_0	3	1	Preferred Generic	1	2	001000		2	011100000010111000000100	30	60	90							1	30	60	90							30		31					0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00							
S5993	001	0		29	10	S5993_001_0	3	5	Specialty Tier	1	2	010010		1	110000000010000000000101	30																			30		31		31	14					25.00	25																																										25				25			25			
S5993	003	0		29	10	S5993_003_0	3	2	Non-Preferred Generic	3	4	000100	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					5.00	10.00	15.00																						2.50	5.00	7.50																		5.00					5.00					1		
S5993	003	0		29	10	S5993_003_0	3	5	Specialty Tier	1	4	010010	1	1	110000000010000000000101	30																			30		31		31	14					33.00	33																																										33				33			33			
S5993	003	0		29	10	S5993_003_0	3	4	Non-Preferred Brand	1	4	100000	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		76.00	152.00	228.00																						76.00	152.00	228.00																		76.00								76.00				
S5993	003	0		29	10	S5993_003_0	3	3	Preferred Brand	1	4	000001	1	2	111100000010111000000001	30	60	90							1	30	60	90							30				31	14		38.00	76.00	114.00																						38.00	76.00	114.00																		38.00								38.00				
S5993	003	0		29	10	S5993_003_0	3	2	Non-Preferred Generic	1	4	000100	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					5.00	10.00	15.00																						2.50	5.00	7.50																		5.00					5.00							
S5993	003	0		29	10	S5993_003_0	3	1	Preferred Generic	1	4	001000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00							
S5993	003	0		29	10	S5993_003_0	3	1	Preferred Generic	3	4	001000	1	2	011100000010111000000100	30	60	90							1	30	60	90							30		31					0.00	0.00	0.00																						0.00	0.00	0.00																		0.00					0.00					1		
S6506	001	0		29	10	S6506_001_0	5	1	Preferred Generic	1	3	001000		2	011100000010001000000110	31	60	90							1			90							31		31	14				3.00	6.00	9.00																								7.50																		3.00					3.00							
S6506	001	0		29	10	S6506_001_0	5	4	Non-Preferred Brand	1	3	100000		1	111100000010001000000001	31	60	90							1			90							31				31	14					44.45	46	46	46																							46																	46							46			
S6506	001	0		29	10	S6506_001_0	5	3	Preferred Brand	1	3	000001		2	111100000010001000000001	31	60	90							1			90							31				31	14		39.00	78.00	117.00																								97.50																		39.00								39.00				
S6506	001	0		29	10	S6506_001_0	5	2	Non-Preferred Generic	1	3	000100		2	011100000010001000000110	31	60	90							1			90							31		31	14				8.00	16.00	24.00																								20.00																		8.00					8.00							
S7694	001	0		29	10	S7694_001_0	1	5	Specialty Tier	1	2	010010		1	110000000010100000000101	30										30									30		34		34	7					363.70	25																							25																			25				25			25			
S7694	001	0		29	10	S7694_001_0	1	4	Non-Preferred Brand	1	2	100000		1	110000000010100000000001	30										30									30				34	7					51.40	28																							28																			28							28			
S7694	001	0		29	10	S7694_001_0	1	3	Preferred Brand	1	2	000001		1	110000000010100000000001	30										30									30				34	7					28.90	23																							23																			23							23			
S7694	001	0		29	10	S7694_001_0	1	2	Non-Preferred Generic	1	2	000100		1	010000000010100000000100	30										30									30		34								5.50	25																							25																			25				25						
S7694	001	0		29	10	S7694_001_0	1	1	Preferred Generic	1	2	001000		1	010000000010100000000100	30										30									30		34								2.70	25																							25																			25				25						
S7694	002	0		29	10	S7694_002_0	1	4	Non-Preferred Brand	1	2	100000		1	110000000010100000000001	30										30									30				34	7					46.30	28																							28																			28							28			
S7694	002	0		29	10	S7694_002_0	1	5	Specialty Tier	1	2	010010		1	110000000010100000000101	30										30									30		34		34	7					452.40	25																							25																			25				25			25			
S7694	002	0		29	10	S7694_002_0	1	3	Preferred Brand	1	2	000001		1	110000000010100000000001	30										30									30				34	7					30.20	23																							23																			23							23			
S7694	002	0		29	10	S7694_002_0	1	2	Non-Preferred Generic	1	2	000100		1	010000000010100000000100	30										30									30		34								5.40	25																							25																			25				25						
S7694	002	0		29	10	S7694_002_0	1	1	Preferred Generic	1	2	001000		1	010000000010100000000100	30										30									30		34								2.90	25																							25																			25				25						
S7694	003	0		29	10	S7694_003_0	1	1	Preferred Generic	1	2	001000		1	010000000010100000000100	30										30									30		34								2.50	25																							25																			25				25						
S7694	003	0		29	10	S7694_003_0	1	4	Non-Preferred Brand	1	2	100000		1	110000000010100000000001	30										30									30				34	7					48.60	28																							28																			28							28			
S7694	003	0		29	10	S7694_003_0	1	3	Preferred Brand	1	2	000001		1	110000000010100000000001	30										30									30				34	7					40.40	23																							23																			23							23			
S7694	003	0		29	10	S7694_003_0	1	2	Non-Preferred Generic	1	2	000100		1	010000000010100000000100	30										30									30		34								7.30	25																							25																			25				25						
S7694	003	0		29	10	S7694_003_0	1	5	Specialty Tier	1	2	010010		1	110000000010100000000101	30										30									30		34		34	7					396.10	25																							25																			25				25			25			
S7694	004	0		29	10	S7694_004_0	1	5	Specialty Tier	1	2	010010		1	110000000010100000000101	30										30									30		34		34	7					378.90	25																							25																			25				25			25			
S7694	004	0		29	10	S7694_004_0	1	1	Preferred Generic	1	2	001000		1	010000000010100000000100	30										30									30		34								2.60	25																							25																			25				25						
S7694	004	0		29	10	S7694_004_0	1	2	Non-Preferred Generic	1	2	000100		1	010000000010100000000100	30										30									30		34								7.30	25																							25																			25				25						
S7694	004	0		29	10	S7694_004_0	1	3	Preferred Brand	1	2	000001		1	110000000010100000000001	30										30									30				34	7					40.50	23																							23																			23							23			
S7694	004	0		29	10	S7694_004_0	1	4	Non-Preferred Brand	1	2	100000		1	110000000010100000000001	30										30									30				34	7					51.50	28																							28																			28							28			
S7694	005	0		29	10	S7694_005_0	1	2	Non-Preferred Generic	1	2	000100		1	010000000010100000000100	30										30									30		34								5.80	25																							25																			25				25						
S7694	005	0		29	10	S7694_005_0	1	3	Preferred Brand	1	2	000001		1	110000000010100000000001	30										30									30				34	7					29.90	23																							23																			23							23			
S7694	005	0		29	10	S7694_005_0	1	4	Non-Preferred Brand	1	2	100000		1	110000000010100000000001	30										30									30				34	7					53.30	28																							28																			28							28			
S7694	005	0		29	10	S7694_005_0	1	5	Specialty Tier	1	2	010010		1	110000000010100000000101	30										30									30		34		34	7					373.30	25																							25																			25				25			25			
S7694	005	0		29	10	S7694_005_0	1	1	Preferred Generic	1	2	001000		1	010000000010100000000100	30										30									30		34								2.90	25																							25																			25				25						
S7694	006	0		29	10	S7694_006_0	1	4	Non-Preferred Brand	1	2	100000		1	110000000010100000000001	30										30									30				34	7					61.80	28																							28																			28							28			
S7694	006	0		29	10	S7694_006_0	1	3	Preferred Brand	1	2	000001		1	110000000010100000000001	30										30									30				34	7					41.60	23																							23																			23							23			
S7694	006	0		29	10	S7694_006_0	1	2	Non-Preferred Generic	1	2	000100		1	010000000010100000000100	30										30									30		34								6.80	25																							25																			25				25						
S7694	006	0		29	10	S7694_006_0	1	1	Preferred Generic	1	2	001000		1	010000000010100000000100	30										30									30		34								1.90	25																							25																			25				25						
S7694	006	0		29	10	S7694_006_0	1	5	Specialty Tier	1	2	010010		1	110000000010100000000101	30										30									30		34		34	7					342.10	25																							25																			25				25			25			
S7694	007	0		29	10	S7694_007_0	1	5	Specialty Tier	1	2	010010		1	110000000010100000000101	30										30									30		34		34	7					364.00	25																							25																			25				25			25			
S7694	007	0		29	10	S7694_007_0	1	4	Non-Preferred Brand	1	2	100000		1	110000000010100000000001	30										30									30				34	7					43.30	28																							28																			28							28			
S7694	007	0		29	10	S7694_007_0	1	3	Preferred Brand	1	2	000001		1	110000000010100000000001	30										30									30				34	7					39.70	23																							23																			23							23			
S7694	007	0		29	10	S7694_007_0	1	1	Preferred Generic	1	2	001000		1	010000000010100000000100	30										30									30		34								2.40	25																							25																			25				25						
S7694	007	0		29	10	S7694_007_0	1	2	Non-Preferred Generic	1	2	000100		1	010000000010100000000100	30										30									30		34								7.50	25																							25																			25				25						
S7694	008	0		29	10	S7694_008_0	1	1	Preferred Generic	1	2	001000		1	010000000010100000000100	30										30									30		34								2.70	25																							25																			25				25						
S7694	008	0		29	10	S7694_008_0	1	2	Non-Preferred Generic	1	2	000100		1	010000000010100000000100	30										30									30		34								5.60	25																							25																			25				25						
S7694	008	0		29	10	S7694_008_0	1	3	Preferred Brand	1	2	000001		1	110000000010100000000001	30										30									30				34	7					28.60	23																							23																			23							23			
S7694	008	0		29	10	S7694_008_0	1	4	Non-Preferred Brand	1	2	100000		1	110000000010100000000001	30										30									30				34	7					51.40	28																							28																			28							28			
S7694	008	0		29	10	S7694_008_0	1	5	Specialty Tier	1	2	010010		1	110000000010100000000101	30										30									30		34		34	7					354.00	25																							25																			25				25			25			
S7694	009	0		29	10	S7694_009_0	1	4	Non-Preferred Brand	1	2	100000		1	110000000010100000000001	30										30									30				34	7					51.20	28																							28																			28							28			
S7694	009	0		29	10	S7694_009_0	1	3	Preferred Brand	1	2	000001		1	110000000010100000000001	30										30									30				34	7					28.30	23																							23																			23							23			
S7694	009	0		29	10	S7694_009_0	1	2	Non-Preferred Generic	1	2	000100		1	010000000010100000000100	30										30									30		34								5.50	25																							25																			25				25						
S7694	009	0		29	10	S7694_009_0	1	1	Preferred Generic	1	2	001000		1	010000000010100000000100	30										30									30		34								2.70	25																							25																			25				25						
S7694	009	0		29	10	S7694_009_0	1	5	Specialty Tier	1	2	010010		1	110000000010100000000101	30										30									30		34		34	7					349.70	25																							25																			25				25			25			
S7694	010	0		29	10	S7694_010_0	1	5	Specialty Tier	1	2	010010		1	110000000010100000000101	30										30									30		34		34	7					406.60	25																							25																			25				25			25			
S7694	010	0		29	10	S7694_010_0	1	3	Preferred Brand	1	2	000001		1	110000000010100000000001	30										30									30				34	7					39.10	23																							23																			23							23			
S7694	010	0		29	10	S7694_010_0	1	2	Non-Preferred Generic	1	2	000100		1	010000000010100000000100	30										30									30		34								6.60	25																							25																			25				25						
S7694	010	0		29	10	S7694_010_0	1	1	Preferred Generic	1	2	001000		1	010000000010100000000100	30										30									30		34								1.90	25																							25																			25				25						
S7694	010	0		29	10	S7694_010_0	1	4	Non-Preferred Brand	1	2	100000		1	110000000010100000000001	30										30									30				34	7					61.20	28																							28																			28							28			
S7694	011	0		29	10	S7694_011_0	1	1	Preferred Generic	1	2	001000		1	010000000010100000000100	30										30									30		34								2.30	25																							25																			25				25						
S7694	011	0		29	10	S7694_011_0	1	2	Non-Preferred Generic	1	2	000100		1	010000000010100000000100	30										30									30		34								7.10	25																							25																			25				25						
S7694	011	0		29	10	S7694_011_0	1	3	Preferred Brand	1	2	000001		1	110000000010100000000001	30										30									30				34	7					38.20	23																							23																			23							23			
S7694	011	0		29	10	S7694_011_0	1	5	Specialty Tier	1	2	010010		1	110000000010100000000101	30										30									30		34		34	7					366.30	25																							25																			25				25			25			
S7694	011	0		29	10	S7694_011_0	1	4	Non-Preferred Brand	1	2	100000		1	110000000010100000000001	30										30									30				34	7					41.50	28																							28																			28							28			
S7694	012	0		29	10	S7694_012_0	1	5	Specialty Tier	1	2	010010		1	110000000010100000000101	30										30									30		34		34	7					382.10	25																							25																			25				25			25			
S7694	012	0		29	10	S7694_012_0	1	1	Preferred Generic	1	2	001000		1	010000000010100000000100	30										30									30		34								1.90	25																							25																			25				25						
S7694	012	0		29	10	S7694_012_0	1	2	Non-Preferred Generic	1	2	000100		1	010000000010100000000100	30										30									30		34								6.30	25																							25																			25				25						
S7694	012	0		29	10	S7694_012_0	1	4	Non-Preferred Brand	1	2	100000		1	110000000010100000000001	30										30									30				34	7					62.70	28																							28																			28							28			
S7694	012	0		29	10	S7694_012_0	1	3	Preferred Brand	1	2	000001		1	110000000010100000000001	30										30									30				34	7					38.80	23																							23																			23							23			
S7694	014	0		29	10	S7694_014_0	1	4	Non-Preferred Brand	1	2	100000		1	110000000010100000000001	30										30									30				34	7					50.40	28																							28																			28							28			
S7694	014	0		29	10	S7694_014_0	1	3	Preferred Brand	1	2	000001		1	110000000010100000000001	30										30									30				34	7					28.00	23																							23																			23							23			
S7694	014	0		29	10	S7694_014_0	1	2	Non-Preferred Generic	1	2	000100		1	010000000010100000000100	30										30									30		34								5.60	25																							25																			25				25						
S7694	014	0		29	10	S7694_014_0	1	1	Preferred Generic	1	2	001000		1	010000000010100000000100	30										30									30		34								2.70	25																							25																			25				25						
S7694	014	0		29	10	S7694_014_0	1	5	Specialty Tier	1	2	010010		1	110000000010100000000101	30										30									30		34		34	7					343.90	25																							25																			25				25			25			
S7694	015	0		29	10	S7694_015_0	1	1	Preferred Generic	1	2	001000		1	010000000010100000000100	30										30									30		34								2.60	25																							25																			25				25						
S7694	015	0		29	10	S7694_015_0	1	5	Specialty Tier	1	2	010010		1	110000000010100000000101	30										30									30		34		34	7					338.50	25																							25																			25				25			25			
S7694	015	0		29	10	S7694_015_0	1	4	Non-Preferred Brand	1	2	100000		1	110000000010100000000001	30										30									30				34	7					48.90	28																							28																			28							28			
S7694	015	0		29	10	S7694_015_0	1	2	Non-Preferred Generic	1	2	000100		1	010000000010100000000100	30										30									30		34								5.30	25																							25																			25				25						
S7694	015	0		29	10	S7694_015_0	1	3	Preferred Brand	1	2	000001		1	110000000010100000000001	30										30									30				34	7					27.40	23																							23																			23							23			
S7694	016	0		29	10	S7694_016_0	1	2	Non-Preferred Generic	1	2	000100		1	010000000010100000000100	30										30									30		34								5.70	25																							25																			25				25						
S7694	016	0		29	10	S7694_016_0	1	5	Specialty Tier	1	2	010010		1	110000000010100000000101	30										30									30		34		34	7					364.00	25																							25																			25				25			25			
S7694	016	0		29	10	S7694_016_0	1	4	Non-Preferred Brand	1	2	100000		1	110000000010100000000001	30										30									30				34	7					51.20	28																							28																			28							28			
S7694	016	0		29	10	S7694_016_0	1	3	Preferred Brand	1	2	000001		1	110000000010100000000001	30										30									30				34	7					29.00	23																							23																			23							23			
S7694	016	0		29	10	S7694_016_0	1	1	Preferred Generic	1	2	001000		1	010000000010100000000100	30										30									30		34								2.80	25																							25																			25				25						
S7694	017	0		29	10	S7694_017_0	1	2	Non-Preferred Generic	1	2	000100		1	010000000010100000000100	30										30									30		34								5.60	25																							25																			25				25						
S7694	017	0		29	10	S7694_017_0	1	3	Preferred Brand	1	2	000001		1	110000000010100000000001	30										30									30				34	7					28.30	23																							23																			23							23			
S7694	017	0		29	10	S7694_017_0	1	4	Non-Preferred Brand	1	2	100000		1	110000000010100000000001	30										30									30				34	7					50.30	28																							28																			28							28			
S7694	017	0		29	10	S7694_017_0	1	1	Preferred Generic	1	2	001000		1	010000000010100000000100	30										30									30		34								2.70	25																							25																			25				25						
S7694	017	0		29	10	S7694_017_0	1	5	Specialty Tier	1	2	010010		1	110000000010100000000101	30										30									30		34		34	7					352.90	25																							25																			25				25			25			
S7694	018	0		29	10	S7694_018_0	1	5	Specialty Tier	1	2	010010		1	110000000010100000000101	30										30									30		34		34	7					380.70	25																							25																			25				25			25			
S7694	018	0		29	10	S7694_018_0	1	3	Preferred Brand	1	2	000001		1	110000000010100000000001	30										30									30				34	7					28.30	23																							23																			23							23			
S7694	018	0		29	10	S7694_018_0	1	4	Non-Preferred Brand	1	2	100000		1	110000000010100000000001	30										30									30				34	7					46.40	28																							28																			28							28			
S7694	018	0		29	10	S7694_018_0	1	2	Non-Preferred Generic	1	2	000100		1	010000000010100000000100	30										30									30		34								5.30	25																							25																			25				25						
S7694	018	0		29	10	S7694_018_0	1	1	Preferred Generic	1	2	001000		1	010000000010100000000100	30										30									30		34								2.70	25																							25																			25				25						
S7694	019	0		29	10	S7694_019_0	1	2	Non-Preferred Generic	1	2	000100		1	010000000010100000000100	30										30									30		34								6.10	25																							25																			25				25						
S7694	019	0		29	10	S7694_019_0	1	3	Preferred Brand	1	2	000001		1	110000000010100000000001	30										30									30				34	7					37.20	23																							23																			23							23			
S7694	019	0		29	10	S7694_019_0	1	5	Specialty Tier	1	2	010010		1	110000000010100000000101	30										30									30		34		34	7					710.50	25																							25																			25				25			25			
S7694	019	0		29	10	S7694_019_0	1	4	Non-Preferred Brand	1	2	100000		1	110000000010100000000001	30										30									30				34	7					61.10	28																							28																			28							28			
S7694	019	0		29	10	S7694_019_0	1	1	Preferred Generic	1	2	001000		1	010000000010100000000100	30										30									30		34								1.70	25																							25																			25				25						
S7694	020	0		29	10	S7694_020_0	1	2	Non-Preferred Generic	1	2	000100		1	010000000010100000000100	30										30									30		34								5.30	25																							25																			25				25						
S7694	020	0		29	10	S7694_020_0	1	3	Preferred Brand	1	2	000001		1	110000000010100000000001	30										30									30				34	7					27.30	23																							23																			23							23			
S7694	020	0		29	10	S7694_020_0	1	4	Non-Preferred Brand	1	2	100000		1	110000000010100000000001	30										30									30				34	7					50.60	28																							28																			28							28			
S7694	020	0		29	10	S7694_020_0	1	5	Specialty Tier	1	2	010010		1	110000000010100000000101	30										30									30		34		34	7					332.60	25																							25																			25				25			25			
S7694	020	0		29	10	S7694_020_0	1	1	Preferred Generic	1	2	001000		1	010000000010100000000100	30										30									30		34								2.50	25																							25																			25				25						
S7694	021	0		29	10	S7694_021_0	1	2	Non-Preferred Generic	1	2	000100		1	010000000010100000000100	30										30									30		34								6.30	25																							25																			25				25						
S7694	021	0		29	10	S7694_021_0	1	3	Preferred Brand	1	2	000001		1	110000000010100000000001	30										30									30				34	7					48.60	23																							23																			23							23			
S7694	021	0		29	10	S7694_021_0	1	4	Non-Preferred Brand	1	2	100000		1	110000000010100000000001	30										30									30				34	7					60.90	28																							28																			28							28			
S7694	021	0		29	10	S7694_021_0	1	5	Specialty Tier	1	2	010010		1	110000000010100000000101	30										30									30		34		34	7					374.70	25																							25																			25				25			25			
S7694	021	0		29	10	S7694_021_0	1	1	Preferred Generic	1	2	001000		1	010000000010100000000100	30										30									30		34								1.70	25																							25																			25				25						
S7694	022	0		29	10	S7694_022_0	1	2	Non-Preferred Generic	1	2	000100		1	010000000010100000000100	30										30									30		34								7.50	25																							25																			25				25						
S7694	022	0		29	10	S7694_022_0	1	3	Preferred Brand	1	2	000001		1	110000000010100000000001	30										30									30				34	7					41.30	23																							23																			23							23			
S7694	022	0		29	10	S7694_022_0	1	1	Preferred Generic	1	2	001000		1	010000000010100000000100	30										30									30		34								2.40	25																							25																			25				25						
S7694	022	0		29	10	S7694_022_0	1	5	Specialty Tier	1	2	010010		1	110000000010100000000101	30										30									30		34		34	7					425.20	25																							25																			25				25			25			
S7694	022	0		29	10	S7694_022_0	1	4	Non-Preferred Brand	1	2	100000		1	110000000010100000000001	30										30									30				34	7					47.50	28																							28																			28							28			
S7694	023	0		29	10	S7694_023_0	1	1	Preferred Generic	1	2	001000		1	010000000010100000000100	30										30									30		34								2.80	25																							25																			25				25						
S7694	023	0		29	10	S7694_023_0	1	5	Specialty Tier	1	2	010010		1	110000000010100000000101	30										30									30		34		34	7					357.00	25																							25																			25				25			25			
S7694	023	0		29	10	S7694_023_0	1	4	Non-Preferred Brand	1	2	100000		1	110000000010100000000001	30										30									30				34	7					50.00	28																							28																			28							28			
S7694	023	0		29	10	S7694_023_0	1	3	Preferred Brand	1	2	000001		1	110000000010100000000001	30										30									30				34	7					28.40	23																							23																			23							23			
S7694	023	0		29	10	S7694_023_0	1	2	Non-Preferred Generic	1	2	000100		1	010000000010100000000100	30										30									30		34								5.60	25																							25																			25				25						
S7694	024	0		29	10	S7694_024_0	1	1	Preferred Generic	1	2	001000		1	010000000010100000000100	30										30									30		34								2.70	25																							25																			25				25						
S7694	024	0		29	10	S7694_024_0	1	5	Specialty Tier	1	2	010010		1	110000000010100000000101	30										30									30		34		34	7					362.60	25																							25																			25				25			25			
S7694	024	0		29	10	S7694_024_0	1	4	Non-Preferred Brand	1	2	100000		1	110000000010100000000001	30										30									30				34	7					49.70	28																							28																			28							28			
S7694	024	0		29	10	S7694_024_0	1	3	Preferred Brand	1	2	000001		1	110000000010100000000001	30										30									30				34	7					28.60	23																							23																			23							23			
S7694	024	0		29	10	S7694_024_0	1	2	Non-Preferred Generic	1	2	000100		1	010000000010100000000100	30										30									30		34								5.50	25																							25																			25				25						
S7694	025	0		29	10	S7694_025_0	1	1	Preferred Generic	1	2	001000		1	010000000010100000000100	30										30									30		34								2.80	25																							25																			25				25						
S7694	025	0		29	10	S7694_025_0	1	5	Specialty Tier	1	2	010010		1	110000000010100000000101	30										30									30		34		34	7					365.80	25																							25																			25				25			25			
S7694	025	0		29	10	S7694_025_0	1	4	Non-Preferred Brand	1	2	100000		1	110000000010100000000001	30										30									30				34	7					52.90	28																							28																			28							28			
S7694	025	0		29	10	S7694_025_0	1	3	Preferred Brand	1	2	000001		1	110000000010100000000001	30										30									30				34	7					29.50	23																							23																			23							23			
S7694	025	0		29	10	S7694_025_0	1	2	Non-Preferred Generic	1	2	000100		1	010000000010100000000100	30										30									30		34								5.80	25																							25																			25				25						
S7694	026	0		29	10	S7694_026_0	1	5	Specialty Tier	1	2	010010		1	110000000010100000000101	30										30									30		34		34	7					378.30	25																							25																			25				25			25			
S7694	026	0		29	10	S7694_026_0	1	4	Non-Preferred Brand	1	2	100000		1	110000000010100000000001	30										30									30				34	7					50.10	28																							28																			28							28			
S7694	026	0		29	10	S7694_026_0	1	2	Non-Preferred Generic	1	2	000100		1	010000000010100000000100	30										30									30		34								5.50	25																							25																			25				25						
S7694	026	0		29	10	S7694_026_0	1	1	Preferred Generic	1	2	001000		1	010000000010100000000100	30										30									30		34								2.90	25																							25																			25				25						
S7694	026	0		29	10	S7694_026_0	1	3	Preferred Brand	1	2	000001		1	110000000010100000000001	30										30									30				34	7					29.20	23																							23																			23							23			
S7694	027	0		29	10	S7694_027_0	1	5	Specialty Tier	1	2	010010		1	110000000010100000000101	30										30									30		34		34	7					379.70	25																							25																			25				25			25			
S7694	027	0		29	10	S7694_027_0	1	1	Preferred Generic	1	2	001000		1	010000000010100000000100	30										30									30		34								2.80	25																							25																			25				25						
S7694	027	0		29	10	S7694_027_0	1	2	Non-Preferred Generic	1	2	000100		1	010000000010100000000100	30										30									30		34								5.70	25																							25																			25				25						
S7694	027	0		29	10	S7694_027_0	1	4	Non-Preferred Brand	1	2	100000		1	110000000010100000000001	30										30									30				34	7					51.80	28																							28																			28							28			
S7694	027	0		29	10	S7694_027_0	1	3	Preferred Brand	1	2	000001		1	110000000010100000000001	30										30									30				34	7					29.70	23																							23																			23							23			
S7694	028	0		29	10	S7694_028_0	1	5	Specialty Tier	1	2	010010		1	110000000010100000000101	30										30									30		34		34	7					408.60	25																							25																			25				25			25			
S7694	028	0		29	10	S7694_028_0	1	4	Non-Preferred Brand	1	2	100000		1	110000000010100000000001	30										30									30				34	7					44.20	28																							28																			28							28			
S7694	028	0		29	10	S7694_028_0	1	2	Non-Preferred Generic	1	2	000100		1	010000000010100000000100	30										30									30		34								5.20	25																							25																			25				25						
S7694	028	0		29	10	S7694_028_0	1	1	Preferred Generic	1	2	001000		1	010000000010100000000100	30										30									30		34								2.80	25																							25																			25				25						
S7694	028	0		29	10	S7694_028_0	1	3	Preferred Brand	1	2	000001		1	110000000010100000000001	30										30									30				34	7					28.30	23																							23																			23							23			
S7694	029	0		29	10	S7694_029_0	1	5	Specialty Tier	1	2	010010		1	110000000010100000000101	30										30									30		34		34	7					465.90	25																							25																			25				25			25			
S7694	029	0		29	10	S7694_029_0	1	4	Non-Preferred Brand	1	2	100000		1	110000000010100000000001	30										30									30				34	7					45.00	28																							28																			28							28			
S7694	029	0		29	10	S7694_029_0	1	3	Preferred Brand	1	2	000001		1	110000000010100000000001	30										30									30				34	7					30.00	23																							23																			23							23			
S7694	029	0		29	10	S7694_029_0	1	2	Non-Preferred Generic	1	2	000100		1	010000000010100000000100	30										30									30		34								5.20	25																							25																			25				25						
S7694	029	0		29	10	S7694_029_0	1	1	Preferred Generic	1	2	001000		1	010000000010100000000100	30										30									30		34								2.90	25																							25																			25				25						
S7694	030	0		29	10	S7694_030_0	1	5	Specialty Tier	1	2	010010		1	110000000010100000000101	30										30									30		34		34	7					359.10	25																							25																			25				25			25			
S7694	030	0		29	10	S7694_030_0	1	1	Preferred Generic	1	2	001000		1	010000000010100000000100	30										30									30		34								2.70	25																							25																			25				25						
S7694	030	0		29	10	S7694_030_0	1	2	Non-Preferred Generic	1	2	000100		1	010000000010100000000100	30										30									30		34								5.60	25																							25																			25				25						
S7694	030	0		29	10	S7694_030_0	1	3	Preferred Brand	1	2	000001		1	110000000010100000000001	30										30									30				34	7					28.70	23																							23																			23							23			
S7694	030	0		29	10	S7694_030_0	1	4	Non-Preferred Brand	1	2	100000		1	110000000010100000000001	30										30									30				34	7					51.00	28																							28																			28							28			
S7694	031	0		29	10	S7694_031_0	1	5	Specialty Tier	1	2	010010		1	110000000010100000000101	30										30									30		34		34	7					372.80	25																							25																			25				25			25			
S7694	031	0		29	10	S7694_031_0	1	4	Non-Preferred Brand	1	2	100000		1	110000000010100000000001	30										30									30				34	7					51.50	28																							28																			28							28			
S7694	031	0		29	10	S7694_031_0	1	3	Preferred Brand	1	2	000001		1	110000000010100000000001	30										30									30				34	7					29.40	23																							23																			23							23			
S7694	031	0		29	10	S7694_031_0	1	2	Non-Preferred Generic	1	2	000100		1	010000000010100000000100	30										30									30		34								5.60	25																							25																			25				25						
S7694	031	0		29	10	S7694_031_0	1	1	Preferred Generic	1	2	001000		1	010000000010100000000100	30										30									30		34								2.80	25																							25																			25				25						
S7694	032	0		29	10	S7694_032_0	1	5	Specialty Tier	1	2	010010		1	110000000010100000000101	30										30									30		34		34	7					366.40	25																							25																			25				25			25			
S7694	032	0		29	10	S7694_032_0	1	4	Non-Preferred Brand	1	2	100000		1	110000000010100000000001	30										30									30				34	7					54.30	28																							28																			28							28			
S7694	032	0		29	10	S7694_032_0	1	3	Preferred Brand	1	2	000001		1	110000000010100000000001	30										30									30				34	7					29.80	23																							23																			23							23			
S7694	032	0		29	10	S7694_032_0	1	1	Preferred Generic	1	2	001000		1	010000000010100000000100	30										30									30		34								2.90	25																							25																			25				25						
S7694	032	0		29	10	S7694_032_0	1	2	Non-Preferred Generic	1	2	000100		1	010000000010100000000100	30										30									30		34								5.90	25																							25																			25				25						
S7694	033	0		29	10	S7694_033_0	1	5	Specialty Tier	1	2	010010		1	110000000010100000000101	30										30									30		34		34	7					410.60	25																							25																			25				25			25			
S7694	033	0		29	10	S7694_033_0	1	1	Preferred Generic	1	2	001000		1	010000000010100000000100	30										30									30		34								2.90	25																							25																			25				25						
S7694	033	0		29	10	S7694_033_0	1	2	Non-Preferred Generic	1	2	000100		1	010000000010100000000100	30										30									30		34								5.60	25																							25																			25				25						
S7694	033	0		29	10	S7694_033_0	1	3	Preferred Brand	1	2	000001		1	110000000010100000000001	30										30									30				34	7					31.20	23																							23																			23							23			
S7694	033	0		29	10	S7694_033_0	1	4	Non-Preferred Brand	1	2	100000		1	110000000010100000000001	30										30									30				34	7					53.40	28																							28																			28							28			
S7694	034	0		29	10	S7694_034_0	1	5	Specialty Tier	1	2	010010		1	110000000010100000000101	30										30									30		34		34	7					410.40	25																							25																			25				25			25			
S7694	034	0		29	10	S7694_034_0	1	1	Preferred Generic	1	2	001000		1	010000000010100000000100	30										30									30		34								2.50	25																							25																			25				25						
S7694	034	0		29	10	S7694_034_0	1	2	Non-Preferred Generic	1	2	000100		1	010000000010100000000100	30										30									30		34								4.60	25																							25																			25				25						
S7694	034	0		29	10	S7694_034_0	1	3	Preferred Brand	1	2	000001		1	110000000010100000000001	30										30									30				34	7					27.30	23																							23																			23							23			
S7694	034	0		29	10	S7694_034_0	1	4	Non-Preferred Brand	1	2	100000		1	110000000010100000000001	30										30									30				34	7					41.50	28																							28																			28							28			
S7694	070	0		29	10	S7694_070_0	2	1	Preferred Generic	1	2	001000		1	010000000010100000000100	30										30									30		34								2.70	25																							25																			25				25						
S7694	070	0		29	10	S7694_070_0	2	5	Specialty Tier	1	2	010010		1	110000000010100000000101	30										30									30		34		34	7					355.00	25																							25																			25				25			25			
S7694	070	0		29	10	S7694_070_0	2	4	Non-Preferred Brand	1	2	100000		1	110000000010100000000001	30										30									30				34	7					51.70	28																							28																			28							28			
S7694	070	0		29	10	S7694_070_0	2	3	Preferred Brand	1	2	000001		1	110000000010100000000001	30										30									30				34	7					28.80	23																							23																			23							23			
S7694	070	0		29	10	S7694_070_0	2	2	Non-Preferred Generic	1	2	000100		1	010000000010100000000100	30										30									30		34								5.60	25																							25																			25				25						
S7694	071	0		29	10	S7694_071_0	3	1	Preferred Generic	1	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	3.00	25		25		2.00	4.00	6.00	1	1	1															2.00		25			2.00	25						
S7694	071	0		29	10	S7694_071_0	3	2	Non-Preferred Generic	1	4	000100	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													5.00	10.00	15.00	5.00	1	1	1		5.00		15.00	5.10	25		25		5.00	10.00	15.00	1	1	1															5.00		25			5.00	25						
S7694	071	0		29	10	S7694_071_0	3	1	Preferred Generic	3	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	8.70	59		59		2.00	4.00	6.00	1	1	1															2.00		59			2.00	59				1		
S7694	071	0		29	10	S7694_071_0	3	3	Preferred Brand	1	4	000001	1	3	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7										25.00	50.00	75.00	25.00	1	1	1		25.00		75.00	33.40	25		25		25.00	50.00	75.00	1	1	1															25.00		25						25.00	25			
S7694	071	0		29	10	S7694_071_0	3	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				30			30				30									30		34		34	7													444.00	29							443.70	29							29																			29				29			29			
S7694	071	0		29	10	S7694_071_0	3	4	Non-Preferred Brand	1	4	100000	1	1	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7													42.60	30	30	30					43.30	30		30					30	30	30																	30							30			
S7694	072	0		29	10	S7694_072_0	3	3	Preferred Brand	1	4	000001	1	3	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7										25.00	50.00	75.00	25.00	1	1	1		25.00		75.00	33.40	25		25		25.00	50.00	75.00	1	1	1															25.00		25						25.00	25			
S7694	072	0		29	10	S7694_072_0	3	1	Preferred Generic	1	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	3.00	25		25		2.00	4.00	6.00	1	1	1															2.00		25			2.00	25						
S7694	072	0		29	10	S7694_072_0	3	2	Non-Preferred Generic	1	4	000100	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													5.00	10.00	15.00	5.00	1	1	1		5.00		15.00	5.10	25		25		5.00	10.00	15.00	1	1	1															5.00		25			5.00	25						
S7694	072	0		29	10	S7694_072_0	3	4	Non-Preferred Brand	1	4	100000	1	1	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7													42.60	30	30	30					43.30	30		30					30	30	30																	30							30			
S7694	072	0		29	10	S7694_072_0	3	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				30			30				30									30		34		34	7													444.00	29							443.70	29							29																			29				29			29			
S7694	072	0		29	10	S7694_072_0	3	1	Preferred Generic	3	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	8.70	59		59		2.00	4.00	6.00	1	1	1															2.00		59			2.00	59				1		
S7694	073	0		29	10	S7694_073_0	3	1	Preferred Generic	3	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	8.70	59		59		2.00	4.00	6.00	1	1	1															2.00		59			2.00	59				1		
S7694	073	0		29	10	S7694_073_0	3	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				30			30				30									30		34		34	7													444.00	29							443.70	29							29																			29				29			29			
S7694	073	0		29	10	S7694_073_0	3	3	Preferred Brand	1	4	000001	1	3	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7										25.00	50.00	75.00	25.00	1	1	1		25.00		75.00	33.40	25		25		25.00	50.00	75.00	1	1	1															25.00		25						25.00	25			
S7694	073	0		29	10	S7694_073_0	3	4	Non-Preferred Brand	1	4	100000	1	1	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7													42.60	30	30	30					43.30	30		30					30	30	30																	30							30			
S7694	073	0		29	10	S7694_073_0	3	1	Preferred Generic	1	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	3.00	25		25		2.00	4.00	6.00	1	1	1															2.00		25			2.00	25						
S7694	073	0		29	10	S7694_073_0	3	2	Non-Preferred Generic	1	4	000100	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													5.00	10.00	15.00	5.00	1	1	1		5.00		15.00	5.10	25		25		5.00	10.00	15.00	1	1	1															5.00		25			5.00	25						
S7694	074	0		29	10	S7694_074_0	3	4	Non-Preferred Brand	1	4	100000	1	1	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7													42.60	30	30	30					43.30	30		30					30	30	30																	30							30			
S7694	074	0		29	10	S7694_074_0	3	1	Preferred Generic	1	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	3.00	25		25		2.00	4.00	6.00	1	1	1															2.00		25			2.00	25						
S7694	074	0		29	10	S7694_074_0	3	2	Non-Preferred Generic	1	4	000100	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													5.00	10.00	15.00	5.00	1	1	1		5.00		15.00	5.10	25		25		5.00	10.00	15.00	1	1	1															5.00		25			5.00	25						
S7694	074	0		29	10	S7694_074_0	3	3	Preferred Brand	1	4	000001	1	3	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7										25.00	50.00	75.00	25.00	1	1	1		25.00		75.00	33.40	25		25		25.00	50.00	75.00	1	1	1															25.00		25						25.00	25			
S7694	074	0		29	10	S7694_074_0	3	1	Preferred Generic	3	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	8.70	59		59		2.00	4.00	6.00	1	1	1															2.00		59			2.00	59				1		
S7694	074	0		29	10	S7694_074_0	3	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				30			30				30									30		34		34	7													444.00	29							443.70	29							29																			29				29			29			
S7694	075	0		29	10	S7694_075_0	3	2	Non-Preferred Generic	1	4	000100	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													5.00	10.00	15.00	5.00	1	1	1		5.00		15.00	5.10	25		25		5.00	10.00	15.00	1	1	1															5.00		25			5.00	25						
S7694	075	0		29	10	S7694_075_0	3	1	Preferred Generic	1	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	3.00	25		25		2.00	4.00	6.00	1	1	1															2.00		25			2.00	25						
S7694	075	0		29	10	S7694_075_0	3	1	Preferred Generic	3	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	8.70	59		59		2.00	4.00	6.00	1	1	1															2.00		59			2.00	59				1		
S7694	075	0		29	10	S7694_075_0	3	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				30			30				30									30		34		34	7													444.00	29							443.70	29							29																			29				29			29			
S7694	075	0		29	10	S7694_075_0	3	4	Non-Preferred Brand	1	4	100000	1	1	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7													42.60	30	30	30					43.30	30		30					30	30	30																	30							30			
S7694	075	0		29	10	S7694_075_0	3	3	Preferred Brand	1	4	000001	1	3	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7										25.00	50.00	75.00	25.00	1	1	1		25.00		75.00	33.40	25		25		25.00	50.00	75.00	1	1	1															25.00		25						25.00	25			
S7694	076	0		29	10	S7694_076_0	3	1	Preferred Generic	3	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	8.70	59		59		2.00	4.00	6.00	1	1	1															2.00		59			2.00	59				1		
S7694	076	0		29	10	S7694_076_0	3	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				30			30				30									30		34		34	7													444.00	29							443.70	29							29																			29				29			29			
S7694	076	0		29	10	S7694_076_0	3	4	Non-Preferred Brand	1	4	100000	1	1	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7													42.60	30	30	30					43.30	30		30					30	30	30																	30							30			
S7694	076	0		29	10	S7694_076_0	3	2	Non-Preferred Generic	1	4	000100	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													5.00	10.00	15.00	5.00	1	1	1		5.00		15.00	5.10	25		25		5.00	10.00	15.00	1	1	1															5.00		25			5.00	25						
S7694	076	0		29	10	S7694_076_0	3	1	Preferred Generic	1	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	3.00	25		25		2.00	4.00	6.00	1	1	1															2.00		25			2.00	25						
S7694	076	0		29	10	S7694_076_0	3	3	Preferred Brand	1	4	000001	1	3	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7										25.00	50.00	75.00	25.00	1	1	1		25.00		75.00	33.40	25		25		25.00	50.00	75.00	1	1	1															25.00		25						25.00	25			
S7694	077	0		29	10	S7694_077_0	3	2	Non-Preferred Generic	1	4	000100	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													5.00	10.00	15.00	5.00	1	1	1		5.00		15.00	5.10	25		25		5.00	10.00	15.00	1	1	1															5.00		25			5.00	25						
S7694	077	0		29	10	S7694_077_0	3	1	Preferred Generic	1	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	3.00	25		25		2.00	4.00	6.00	1	1	1															2.00		25			2.00	25						
S7694	077	0		29	10	S7694_077_0	3	3	Preferred Brand	1	4	000001	1	3	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7										25.00	50.00	75.00	25.00	1	1	1		25.00		75.00	33.40	25		25		25.00	50.00	75.00	1	1	1															25.00		25						25.00	25			
S7694	077	0		29	10	S7694_077_0	3	4	Non-Preferred Brand	1	4	100000	1	1	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7													42.60	30	30	30					43.30	30		30					30	30	30																	30							30			
S7694	077	0		29	10	S7694_077_0	3	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				30			30				30									30		34		34	7													444.00	29							443.70	29							29																			29				29			29			
S7694	077	0		29	10	S7694_077_0	3	1	Preferred Generic	3	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	8.70	59		59		2.00	4.00	6.00	1	1	1															2.00		59			2.00	59				1		
S7694	078	0		29	10	S7694_078_0	3	2	Non-Preferred Generic	1	4	000100	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													5.00	10.00	15.00	5.00	1	1	1		5.00		15.00	5.10	25		25		5.00	10.00	15.00	1	1	1															5.00		25			5.00	25						
S7694	078	0		29	10	S7694_078_0	3	1	Preferred Generic	1	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	3.00	25		25		2.00	4.00	6.00	1	1	1															2.00		25			2.00	25						
S7694	078	0		29	10	S7694_078_0	3	3	Preferred Brand	1	4	000001	1	3	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7										25.00	50.00	75.00	25.00	1	1	1		25.00		75.00	33.40	25		25		25.00	50.00	75.00	1	1	1															25.00		25						25.00	25			
S7694	078	0		29	10	S7694_078_0	3	1	Preferred Generic	3	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	8.70	59		59		2.00	4.00	6.00	1	1	1															2.00		59			2.00	59				1		
S7694	078	0		29	10	S7694_078_0	3	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				30			30				30									30		34		34	7													444.00	29							443.70	29							29																			29				29			29			
S7694	078	0		29	10	S7694_078_0	3	4	Non-Preferred Brand	1	4	100000	1	1	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7													42.60	30	30	30					43.30	30		30					30	30	30																	30							30			
S7694	079	0		29	10	S7694_079_0	3	1	Preferred Generic	1	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	3.00	25		25		2.00	4.00	6.00	1	1	1															2.00		25			2.00	25						
S7694	079	0		29	10	S7694_079_0	3	2	Non-Preferred Generic	1	4	000100	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													5.00	10.00	15.00	5.00	1	1	1		5.00		15.00	5.10	25		25		5.00	10.00	15.00	1	1	1															5.00		25			5.00	25						
S7694	079	0		29	10	S7694_079_0	3	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				30			30				30									30		34		34	7													444.00	29							443.70	29							29																			29				29			29			
S7694	079	0		29	10	S7694_079_0	3	4	Non-Preferred Brand	1	4	100000	1	1	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7													42.60	30	30	30					43.30	30		30					30	30	30																	30							30			
S7694	079	0		29	10	S7694_079_0	3	3	Preferred Brand	1	4	000001	1	3	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7										25.00	50.00	75.00	25.00	1	1	1		25.00		75.00	33.40	25		25		25.00	50.00	75.00	1	1	1															25.00		25						25.00	25			
S7694	079	0		29	10	S7694_079_0	3	1	Preferred Generic	3	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	8.70	59		59		2.00	4.00	6.00	1	1	1															2.00		59			2.00	59				1		
S7694	080	0		29	10	S7694_080_0	3	1	Preferred Generic	1	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	3.00	25		25		2.00	4.00	6.00	1	1	1															2.00		25			2.00	25						
S7694	080	0		29	10	S7694_080_0	3	1	Preferred Generic	3	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	8.70	59		59		2.00	4.00	6.00	1	1	1															2.00		59			2.00	59				1		
S7694	080	0		29	10	S7694_080_0	3	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				30			30				30									30		34		34	7													444.00	29							443.70	29							29																			29				29			29			
S7694	080	0		29	10	S7694_080_0	3	4	Non-Preferred Brand	1	4	100000	1	1	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7													42.60	30	30	30					43.30	30		30					30	30	30																	30							30			
S7694	080	0		29	10	S7694_080_0	3	3	Preferred Brand	1	4	000001	1	3	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7										25.00	50.00	75.00	25.00	1	1	1		25.00		75.00	33.40	25		25		25.00	50.00	75.00	1	1	1															25.00		25						25.00	25			
S7694	080	0		29	10	S7694_080_0	3	2	Non-Preferred Generic	1	4	000100	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													5.00	10.00	15.00	5.00	1	1	1		5.00		15.00	5.10	25		25		5.00	10.00	15.00	1	1	1															5.00		25			5.00	25						
S7694	081	0		29	10	S7694_081_0	3	1	Preferred Generic	1	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	3.00	25		25		2.00	4.00	6.00	1	1	1															2.00		25			2.00	25						
S7694	081	0		29	10	S7694_081_0	3	2	Non-Preferred Generic	1	4	000100	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													5.00	10.00	15.00	5.00	1	1	1		5.00		15.00	5.10	25		25		5.00	10.00	15.00	1	1	1															5.00		25			5.00	25						
S7694	081	0		29	10	S7694_081_0	3	3	Preferred Brand	1	4	000001	1	3	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7										25.00	50.00	75.00	25.00	1	1	1		25.00		75.00	33.40	25		25		25.00	50.00	75.00	1	1	1															25.00		25						25.00	25			
S7694	081	0		29	10	S7694_081_0	3	4	Non-Preferred Brand	1	4	100000	1	1	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7													42.60	30	30	30					43.30	30		30					30	30	30																	30							30			
S7694	081	0		29	10	S7694_081_0	3	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				30			30				30									30		34		34	7													444.00	29							443.70	29							29																			29				29			29			
S7694	081	0		29	10	S7694_081_0	3	1	Preferred Generic	3	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	8.70	59		59		2.00	4.00	6.00	1	1	1															2.00		59			2.00	59				1		
S7694	082	0		29	10	S7694_082_0	3	1	Preferred Generic	3	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	8.70	59		59		2.00	4.00	6.00	1	1	1															2.00		59			2.00	59				1		
S7694	082	0		29	10	S7694_082_0	3	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				30			30				30									30		34		34	7													444.00	29							443.70	29							29																			29				29			29			
S7694	082	0		29	10	S7694_082_0	3	4	Non-Preferred Brand	1	4	100000	1	1	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7													42.60	30	30	30					43.30	30		30					30	30	30																	30							30			
S7694	082	0		29	10	S7694_082_0	3	3	Preferred Brand	1	4	000001	1	3	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7										25.00	50.00	75.00	25.00	1	1	1		25.00		75.00	33.40	25		25		25.00	50.00	75.00	1	1	1															25.00		25						25.00	25			
S7694	082	0		29	10	S7694_082_0	3	2	Non-Preferred Generic	1	4	000100	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													5.00	10.00	15.00	5.00	1	1	1		5.00		15.00	5.10	25		25		5.00	10.00	15.00	1	1	1															5.00		25			5.00	25						
S7694	082	0		29	10	S7694_082_0	3	1	Preferred Generic	1	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	3.00	25		25		2.00	4.00	6.00	1	1	1															2.00		25			2.00	25						
S7694	083	0		29	10	S7694_083_0	3	1	Preferred Generic	1	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	3.00	25		25		2.00	4.00	6.00	1	1	1															2.00		25			2.00	25						
S7694	083	0		29	10	S7694_083_0	3	1	Preferred Generic	3	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	8.70	59		59		2.00	4.00	6.00	1	1	1															2.00		59			2.00	59				1		
S7694	083	0		29	10	S7694_083_0	3	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				30			30				30									30		34		34	7													444.00	29							443.70	29							29																			29				29			29			
S7694	083	0		29	10	S7694_083_0	3	4	Non-Preferred Brand	1	4	100000	1	1	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7													42.60	30	30	30					43.30	30		30					30	30	30																	30							30			
S7694	083	0		29	10	S7694_083_0	3	3	Preferred Brand	1	4	000001	1	3	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7										25.00	50.00	75.00	25.00	1	1	1		25.00		75.00	33.40	25		25		25.00	50.00	75.00	1	1	1															25.00		25						25.00	25			
S7694	083	0		29	10	S7694_083_0	3	2	Non-Preferred Generic	1	4	000100	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													5.00	10.00	15.00	5.00	1	1	1		5.00		15.00	5.10	25		25		5.00	10.00	15.00	1	1	1															5.00		25			5.00	25						
S7694	084	0		29	10	S7694_084_0	3	1	Preferred Generic	3	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	8.70	59		59		2.00	4.00	6.00	1	1	1															2.00		59			2.00	59				1		
S7694	084	0		29	10	S7694_084_0	3	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				30			30				30									30		34		34	7													444.00	29							443.70	29							29																			29				29			29			
S7694	084	0		29	10	S7694_084_0	3	4	Non-Preferred Brand	1	4	100000	1	1	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7													42.60	30	30	30					43.30	30		30					30	30	30																	30							30			
S7694	084	0		29	10	S7694_084_0	3	3	Preferred Brand	1	4	000001	1	3	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7										25.00	50.00	75.00	25.00	1	1	1		25.00		75.00	33.40	25		25		25.00	50.00	75.00	1	1	1															25.00		25						25.00	25			
S7694	084	0		29	10	S7694_084_0	3	2	Non-Preferred Generic	1	4	000100	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													5.00	10.00	15.00	5.00	1	1	1		5.00		15.00	5.10	25		25		5.00	10.00	15.00	1	1	1															5.00		25			5.00	25						
S7694	084	0		29	10	S7694_084_0	3	1	Preferred Generic	1	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	3.00	25		25		2.00	4.00	6.00	1	1	1															2.00		25			2.00	25						
S7694	085	0		29	10	S7694_085_0	3	1	Preferred Generic	1	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	3.00	25		25		2.00	4.00	6.00	1	1	1															2.00		25			2.00	25						
S7694	085	0		29	10	S7694_085_0	3	2	Non-Preferred Generic	1	4	000100	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													5.00	10.00	15.00	5.00	1	1	1		5.00		15.00	5.10	25		25		5.00	10.00	15.00	1	1	1															5.00		25			5.00	25						
S7694	085	0		29	10	S7694_085_0	3	3	Preferred Brand	1	4	000001	1	3	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7										25.00	50.00	75.00	25.00	1	1	1		25.00		75.00	33.40	25		25		25.00	50.00	75.00	1	1	1															25.00		25						25.00	25			
S7694	085	0		29	10	S7694_085_0	3	4	Non-Preferred Brand	1	4	100000	1	1	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7													42.60	30	30	30					43.30	30		30					30	30	30																	30							30			
S7694	085	0		29	10	S7694_085_0	3	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				30			30				30									30		34		34	7													444.00	29							443.70	29							29																			29				29			29			
S7694	085	0		29	10	S7694_085_0	3	1	Preferred Generic	3	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	8.70	59		59		2.00	4.00	6.00	1	1	1															2.00		59			2.00	59				1		
S7694	086	0		29	10	S7694_086_0	3	1	Preferred Generic	1	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	3.00	25		25		2.00	4.00	6.00	1	1	1															2.00		25			2.00	25						
S7694	086	0		29	10	S7694_086_0	3	2	Non-Preferred Generic	1	4	000100	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													5.00	10.00	15.00	5.00	1	1	1		5.00		15.00	5.10	25		25		5.00	10.00	15.00	1	1	1															5.00		25			5.00	25						
S7694	086	0		29	10	S7694_086_0	3	3	Preferred Brand	1	4	000001	1	3	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7										25.00	50.00	75.00	25.00	1	1	1		25.00		75.00	33.40	25		25		25.00	50.00	75.00	1	1	1															25.00		25						25.00	25			
S7694	086	0		29	10	S7694_086_0	3	4	Non-Preferred Brand	1	4	100000	1	1	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7													42.60	30	30	30					43.30	30		30					30	30	30																	30							30			
S7694	086	0		29	10	S7694_086_0	3	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				30			30				30									30		34		34	7													444.00	29							443.70	29							29																			29				29			29			
S7694	086	0		29	10	S7694_086_0	3	1	Preferred Generic	3	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	8.70	59		59		2.00	4.00	6.00	1	1	1															2.00		59			2.00	59				1		
S7694	087	0		29	10	S7694_087_0	3	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				30			30				30									30		34		34	7													444.00	29							443.70	29							29																			29				29			29			
S7694	087	0		29	10	S7694_087_0	3	4	Non-Preferred Brand	1	4	100000	1	1	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7													42.60	30	30	30					43.30	30		30					30	30	30																	30							30			
S7694	087	0		29	10	S7694_087_0	3	3	Preferred Brand	1	4	000001	1	3	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7										25.00	50.00	75.00	25.00	1	1	1		25.00		75.00	33.40	25		25		25.00	50.00	75.00	1	1	1															25.00		25						25.00	25			
S7694	087	0		29	10	S7694_087_0	3	2	Non-Preferred Generic	1	4	000100	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													5.00	10.00	15.00	5.00	1	1	1		5.00		15.00	5.10	25		25		5.00	10.00	15.00	1	1	1															5.00		25			5.00	25						
S7694	087	0		29	10	S7694_087_0	3	1	Preferred Generic	1	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	3.00	25		25		2.00	4.00	6.00	1	1	1															2.00		25			2.00	25						
S7694	087	0		29	10	S7694_087_0	3	1	Preferred Generic	3	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	8.70	59		59		2.00	4.00	6.00	1	1	1															2.00		59			2.00	59				1		
S7694	088	0		29	10	S7694_088_0	3	2	Non-Preferred Generic	1	4	000100	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													5.00	10.00	15.00	5.00	1	1	1		5.00		15.00	5.10	25		25		5.00	10.00	15.00	1	1	1															5.00		25			5.00	25						
S7694	088	0		29	10	S7694_088_0	3	3	Preferred Brand	1	4	000001	1	3	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7										25.00	50.00	75.00	25.00	1	1	1		25.00		75.00	33.40	25		25		25.00	50.00	75.00	1	1	1															25.00		25						25.00	25			
S7694	088	0		29	10	S7694_088_0	3	4	Non-Preferred Brand	1	4	100000	1	1	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7													42.60	30	30	30					43.30	30		30					30	30	30																	30							30			
S7694	088	0		29	10	S7694_088_0	3	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				30			30				30									30		34		34	7													444.00	29							443.70	29							29																			29				29			29			
S7694	088	0		29	10	S7694_088_0	3	1	Preferred Generic	3	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	8.70	59		59		2.00	4.00	6.00	1	1	1															2.00		59			2.00	59				1		
S7694	088	0		29	10	S7694_088_0	3	1	Preferred Generic	1	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	3.00	25		25		2.00	4.00	6.00	1	1	1															2.00		25			2.00	25						
S7694	089	0		29	10	S7694_089_0	3	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				30			30				30									30		34		34	7													444.00	29							443.70	29							29																			29				29			29			
S7694	089	0		29	10	S7694_089_0	3	1	Preferred Generic	3	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	8.70	59		59		2.00	4.00	6.00	1	1	1															2.00		59			2.00	59				1		
S7694	089	0		29	10	S7694_089_0	3	4	Non-Preferred Brand	1	4	100000	1	1	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7													42.60	30	30	30					43.30	30		30					30	30	30																	30							30			
S7694	089	0		29	10	S7694_089_0	3	3	Preferred Brand	1	4	000001	1	3	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7										25.00	50.00	75.00	25.00	1	1	1		25.00		75.00	33.40	25		25		25.00	50.00	75.00	1	1	1															25.00		25						25.00	25			
S7694	089	0		29	10	S7694_089_0	3	2	Non-Preferred Generic	1	4	000100	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													5.00	10.00	15.00	5.00	1	1	1		5.00		15.00	5.10	25		25		5.00	10.00	15.00	1	1	1															5.00		25			5.00	25						
S7694	089	0		29	10	S7694_089_0	3	1	Preferred Generic	1	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	3.00	25		25		2.00	4.00	6.00	1	1	1															2.00		25			2.00	25						
S7694	090	0		29	10	S7694_090_0	3	1	Preferred Generic	3	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	8.70	59		59		2.00	4.00	6.00	1	1	1															2.00		59			2.00	59				1		
S7694	090	0		29	10	S7694_090_0	3	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				30			30				30									30		34		34	7													444.00	29							443.70	29							29																			29				29			29			
S7694	090	0		29	10	S7694_090_0	3	4	Non-Preferred Brand	1	4	100000	1	1	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7													42.60	30	30	30					43.30	30		30					30	30	30																	30							30			
S7694	090	0		29	10	S7694_090_0	3	3	Preferred Brand	1	4	000001	1	3	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7										25.00	50.00	75.00	25.00	1	1	1		25.00		75.00	33.40	25		25		25.00	50.00	75.00	1	1	1															25.00		25						25.00	25			
S7694	090	0		29	10	S7694_090_0	3	2	Non-Preferred Generic	1	4	000100	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													5.00	10.00	15.00	5.00	1	1	1		5.00		15.00	5.10	25		25		5.00	10.00	15.00	1	1	1															5.00		25			5.00	25						
S7694	090	0		29	10	S7694_090_0	3	1	Preferred Generic	1	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	3.00	25		25		2.00	4.00	6.00	1	1	1															2.00		25			2.00	25						
S7694	091	0		29	10	S7694_091_0	3	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				30			30				30									30		34		34	7													444.00	29							443.70	29							29																			29				29			29			
S7694	091	0		29	10	S7694_091_0	3	1	Preferred Generic	3	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	8.70	59		59		2.00	4.00	6.00	1	1	1															2.00		59			2.00	59				1		
S7694	091	0		29	10	S7694_091_0	3	4	Non-Preferred Brand	1	4	100000	1	1	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7													42.60	30	30	30					43.30	30		30					30	30	30																	30							30			
S7694	091	0		29	10	S7694_091_0	3	3	Preferred Brand	1	4	000001	1	3	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7										25.00	50.00	75.00	25.00	1	1	1		25.00		75.00	33.40	25		25		25.00	50.00	75.00	1	1	1															25.00		25						25.00	25			
S7694	091	0		29	10	S7694_091_0	3	2	Non-Preferred Generic	1	4	000100	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													5.00	10.00	15.00	5.00	1	1	1		5.00		15.00	5.10	25		25		5.00	10.00	15.00	1	1	1															5.00		25			5.00	25						
S7694	091	0		29	10	S7694_091_0	3	1	Preferred Generic	1	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	3.00	25		25		2.00	4.00	6.00	1	1	1															2.00		25			2.00	25						
S7694	092	0		29	10	S7694_092_0	3	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				30			30				30									30		34		34	7													444.00	29							443.70	29							29																			29				29			29			
S7694	092	0		29	10	S7694_092_0	3	4	Non-Preferred Brand	1	4	100000	1	1	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7													42.60	30	30	30					43.30	30		30					30	30	30																	30							30			
S7694	092	0		29	10	S7694_092_0	3	3	Preferred Brand	1	4	000001	1	3	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7										25.00	50.00	75.00	25.00	1	1	1		25.00		75.00	33.40	25		25		25.00	50.00	75.00	1	1	1															25.00		25						25.00	25			
S7694	092	0		29	10	S7694_092_0	3	2	Non-Preferred Generic	1	4	000100	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													5.00	10.00	15.00	5.00	1	1	1		5.00		15.00	5.10	25		25		5.00	10.00	15.00	1	1	1															5.00		25			5.00	25						
S7694	092	0		29	10	S7694_092_0	3	1	Preferred Generic	1	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	3.00	25		25		2.00	4.00	6.00	1	1	1															2.00		25			2.00	25						
S7694	092	0		29	10	S7694_092_0	3	1	Preferred Generic	3	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	8.70	59		59		2.00	4.00	6.00	1	1	1															2.00		59			2.00	59				1		
S7694	093	0		29	10	S7694_093_0	3	1	Preferred Generic	3	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	8.70	59		59		2.00	4.00	6.00	1	1	1															2.00		59			2.00	59				1		
S7694	093	0		29	10	S7694_093_0	3	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				30			30				30									30		34		34	7													444.00	29							443.70	29							29																			29				29			29			
S7694	093	0		29	10	S7694_093_0	3	4	Non-Preferred Brand	1	4	100000	1	1	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7													42.60	30	30	30					43.30	30		30					30	30	30																	30							30			
S7694	093	0		29	10	S7694_093_0	3	3	Preferred Brand	1	4	000001	1	3	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7										25.00	50.00	75.00	25.00	1	1	1		25.00		75.00	33.40	25		25		25.00	50.00	75.00	1	1	1															25.00		25						25.00	25			
S7694	093	0		29	10	S7694_093_0	3	1	Preferred Generic	1	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	3.00	25		25		2.00	4.00	6.00	1	1	1															2.00		25			2.00	25						
S7694	093	0		29	10	S7694_093_0	3	2	Non-Preferred Generic	1	4	000100	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													5.00	10.00	15.00	5.00	1	1	1		5.00		15.00	5.10	25		25		5.00	10.00	15.00	1	1	1															5.00		25			5.00	25						
S7694	094	0		29	10	S7694_094_0	3	1	Preferred Generic	1	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	3.00	25		25		2.00	4.00	6.00	1	1	1															2.00		25			2.00	25						
S7694	094	0		29	10	S7694_094_0	3	2	Non-Preferred Generic	1	4	000100	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													5.00	10.00	15.00	5.00	1	1	1		5.00		15.00	5.10	25		25		5.00	10.00	15.00	1	1	1															5.00		25			5.00	25						
S7694	094	0		29	10	S7694_094_0	3	3	Preferred Brand	1	4	000001	1	3	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7										25.00	50.00	75.00	25.00	1	1	1		25.00		75.00	33.40	25		25		25.00	50.00	75.00	1	1	1															25.00		25						25.00	25			
S7694	094	0		29	10	S7694_094_0	3	4	Non-Preferred Brand	1	4	100000	1	1	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7													42.60	30	30	30					43.30	30		30					30	30	30																	30							30			
S7694	094	0		29	10	S7694_094_0	3	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				30			30				30									30		34		34	7													444.00	29							443.70	29							29																			29				29			29			
S7694	094	0		29	10	S7694_094_0	3	1	Preferred Generic	3	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	8.70	59		59		2.00	4.00	6.00	1	1	1															2.00		59			2.00	59				1		
S7694	095	0		29	10	S7694_095_0	3	1	Preferred Generic	1	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	3.00	25		25		2.00	4.00	6.00	1	1	1															2.00		25			2.00	25						
S7694	095	0		29	10	S7694_095_0	3	2	Non-Preferred Generic	1	4	000100	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													5.00	10.00	15.00	5.00	1	1	1		5.00		15.00	5.10	25		25		5.00	10.00	15.00	1	1	1															5.00		25			5.00	25						
S7694	095	0		29	10	S7694_095_0	3	3	Preferred Brand	1	4	000001	1	3	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7										25.00	50.00	75.00	25.00	1	1	1		25.00		75.00	33.40	25		25		25.00	50.00	75.00	1	1	1															25.00		25						25.00	25			
S7694	095	0		29	10	S7694_095_0	3	4	Non-Preferred Brand	1	4	100000	1	1	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7													42.60	30	30	30					43.30	30		30					30	30	30																	30							30			
S7694	095	0		29	10	S7694_095_0	3	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				30			30				30									30		34		34	7													444.00	29							443.70	29							29																			29				29			29			
S7694	095	0		29	10	S7694_095_0	3	1	Preferred Generic	3	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	8.70	59		59		2.00	4.00	6.00	1	1	1															2.00		59			2.00	59				1		
S7694	096	0		29	10	S7694_096_0	3	1	Preferred Generic	1	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	3.00	25		25		2.00	4.00	6.00	1	1	1															2.00		25			2.00	25						
S7694	096	0		29	10	S7694_096_0	3	2	Non-Preferred Generic	1	4	000100	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													5.00	10.00	15.00	5.00	1	1	1		5.00		15.00	5.10	25		25		5.00	10.00	15.00	1	1	1															5.00		25			5.00	25						
S7694	096	0		29	10	S7694_096_0	3	3	Preferred Brand	1	4	000001	1	3	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7										25.00	50.00	75.00	25.00	1	1	1		25.00		75.00	33.40	25		25		25.00	50.00	75.00	1	1	1															25.00		25						25.00	25			
S7694	096	0		29	10	S7694_096_0	3	4	Non-Preferred Brand	1	4	100000	1	1	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7													42.60	30	30	30					43.30	30		30					30	30	30																	30							30			
S7694	096	0		29	10	S7694_096_0	3	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				30			30				30									30		34		34	7													444.00	29							443.70	29							29																			29				29			29			
S7694	096	0		29	10	S7694_096_0	3	1	Preferred Generic	3	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	8.70	59		59		2.00	4.00	6.00	1	1	1															2.00		59			2.00	59				1		
S7694	097	0		29	10	S7694_097_0	3	3	Preferred Brand	1	4	000001	1	3	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7										25.00	50.00	75.00	25.00	1	1	1		25.00		75.00	33.40	25		25		25.00	50.00	75.00	1	1	1															25.00		25						25.00	25			
S7694	097	0		29	10	S7694_097_0	3	1	Preferred Generic	3	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	8.70	59		59		2.00	4.00	6.00	1	1	1															2.00		59			2.00	59				1		
S7694	097	0		29	10	S7694_097_0	3	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				30			30				30									30		34		34	7													444.00	29							443.70	29							29																			29				29			29			
S7694	097	0		29	10	S7694_097_0	3	4	Non-Preferred Brand	1	4	100000	1	1	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7													42.60	30	30	30					43.30	30		30					30	30	30																	30							30			
S7694	097	0		29	10	S7694_097_0	3	2	Non-Preferred Generic	1	4	000100	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													5.00	10.00	15.00	5.00	1	1	1		5.00		15.00	5.10	25		25		5.00	10.00	15.00	1	1	1															5.00		25			5.00	25						
S7694	097	0		29	10	S7694_097_0	3	1	Preferred Generic	1	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	3.00	25		25		2.00	4.00	6.00	1	1	1															2.00		25			2.00	25						
S7694	098	0		29	10	S7694_098_0	3	1	Preferred Generic	3	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	8.70	59		59		2.00	4.00	6.00	1	1	1															2.00		59			2.00	59				1		
S7694	098	0		29	10	S7694_098_0	3	3	Preferred Brand	1	4	000001	1	3	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7										25.00	50.00	75.00	25.00	1	1	1		25.00		75.00	33.40	25		25		25.00	50.00	75.00	1	1	1															25.00		25						25.00	25			
S7694	098	0		29	10	S7694_098_0	3	4	Non-Preferred Brand	1	4	100000	1	1	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7													42.60	30	30	30					43.30	30		30					30	30	30																	30							30			
S7694	098	0		29	10	S7694_098_0	3	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				30			30				30									30		34		34	7													444.00	29							443.70	29							29																			29				29			29			
S7694	098	0		29	10	S7694_098_0	3	2	Non-Preferred Generic	1	4	000100	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													5.00	10.00	15.00	5.00	1	1	1		5.00		15.00	5.10	25		25		5.00	10.00	15.00	1	1	1															5.00		25			5.00	25						
S7694	098	0		29	10	S7694_098_0	3	1	Preferred Generic	1	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	3.00	25		25		2.00	4.00	6.00	1	1	1															2.00		25			2.00	25						
S7694	099	0		29	10	S7694_099_0	3	3	Preferred Brand	1	4	000001	1	3	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7										25.00	50.00	75.00	25.00	1	1	1		25.00		75.00	33.40	25		25		25.00	50.00	75.00	1	1	1															25.00		25						25.00	25			
S7694	099	0		29	10	S7694_099_0	3	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				30			30				30									30		34		34	7													444.00	29							443.70	29							29																			29				29			29			
S7694	099	0		29	10	S7694_099_0	3	1	Preferred Generic	3	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	8.70	59		59		2.00	4.00	6.00	1	1	1															2.00		59			2.00	59				1		
S7694	099	0		29	10	S7694_099_0	3	4	Non-Preferred Brand	1	4	100000	1	1	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7													42.60	30	30	30					43.30	30		30					30	30	30																	30							30			
S7694	099	0		29	10	S7694_099_0	3	2	Non-Preferred Generic	1	4	000100	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													5.00	10.00	15.00	5.00	1	1	1		5.00		15.00	5.10	25		25		5.00	10.00	15.00	1	1	1															5.00		25			5.00	25						
S7694	099	0		29	10	S7694_099_0	3	1	Preferred Generic	1	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	3.00	25		25		2.00	4.00	6.00	1	1	1															2.00		25			2.00	25						
S7694	100	0		29	10	S7694_100_0	3	1	Preferred Generic	3	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	8.70	59		59		2.00	4.00	6.00	1	1	1															2.00		59			2.00	59				1		
S7694	100	0		29	10	S7694_100_0	3	1	Preferred Generic	1	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	3.00	25		25		2.00	4.00	6.00	1	1	1															2.00		25			2.00	25						
S7694	100	0		29	10	S7694_100_0	3	4	Non-Preferred Brand	1	4	100000	1	1	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7													42.60	30	30	30					43.30	30		30					30	30	30																	30							30			
S7694	100	0		29	10	S7694_100_0	3	3	Preferred Brand	1	4	000001	1	3	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7										25.00	50.00	75.00	25.00	1	1	1		25.00		75.00	33.40	25		25		25.00	50.00	75.00	1	1	1															25.00		25						25.00	25			
S7694	100	0		29	10	S7694_100_0	3	2	Non-Preferred Generic	1	4	000100	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													5.00	10.00	15.00	5.00	1	1	1		5.00		15.00	5.10	25		25		5.00	10.00	15.00	1	1	1															5.00		25			5.00	25						
S7694	100	0		29	10	S7694_100_0	3	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				30			30				30									30		34		34	7													444.00	29							443.70	29							29																			29				29			29			
S7694	101	0		29	10	S7694_101_0	3	1	Preferred Generic	1	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	3.00	25		25		2.00	4.00	6.00	1	1	1															2.00		25			2.00	25						
S7694	101	0		29	10	S7694_101_0	3	2	Non-Preferred Generic	1	4	000100	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													5.00	10.00	15.00	5.00	1	1	1		5.00		15.00	5.10	25		25		5.00	10.00	15.00	1	1	1															5.00		25			5.00	25						
S7694	101	0		29	10	S7694_101_0	3	3	Preferred Brand	1	4	000001	1	3	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7										25.00	50.00	75.00	25.00	1	1	1		25.00		75.00	33.40	25		25		25.00	50.00	75.00	1	1	1															25.00		25						25.00	25			
S7694	101	0		29	10	S7694_101_0	3	4	Non-Preferred Brand	1	4	100000	1	1	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7													42.60	30	30	30					43.30	30		30					30	30	30																	30							30			
S7694	101	0		29	10	S7694_101_0	3	1	Preferred Generic	3	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	8.70	59		59		2.00	4.00	6.00	1	1	1															2.00		59			2.00	59				1		
S7694	101	0		29	10	S7694_101_0	3	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				30			30				30									30		34		34	7													444.00	29							443.70	29							29																			29				29			29			
S7694	102	0		29	10	S7694_102_0	3	1	Preferred Generic	3	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	8.70	59		59		2.00	4.00	6.00	1	1	1															2.00		59			2.00	59				1		
S7694	102	0		29	10	S7694_102_0	3	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				30			30				30									30		34		34	7													444.00	29							443.70	29							29																			29				29			29			
S7694	102	0		29	10	S7694_102_0	3	2	Non-Preferred Generic	1	4	000100	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													5.00	10.00	15.00	5.00	1	1	1		5.00		15.00	5.10	25		25		5.00	10.00	15.00	1	1	1															5.00		25			5.00	25						
S7694	102	0		29	10	S7694_102_0	3	3	Preferred Brand	1	4	000001	1	3	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7										25.00	50.00	75.00	25.00	1	1	1		25.00		75.00	33.40	25		25		25.00	50.00	75.00	1	1	1															25.00		25						25.00	25			
S7694	102	0		29	10	S7694_102_0	3	4	Non-Preferred Brand	1	4	100000	1	1	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7													42.60	30	30	30					43.30	30		30					30	30	30																	30							30			
S7694	102	0		29	10	S7694_102_0	3	1	Preferred Generic	1	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	3.00	25		25		2.00	4.00	6.00	1	1	1															2.00		25			2.00	25						
S7694	103	0		29	10	S7694_103_0	3	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				30			30				30									30		34		34	7													444.00	29							443.70	29							29																			29				29			29			
S7694	103	0		29	10	S7694_103_0	3	1	Preferred Generic	1	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	3.00	25		25		2.00	4.00	6.00	1	1	1															2.00		25			2.00	25						
S7694	103	0		29	10	S7694_103_0	3	2	Non-Preferred Generic	1	4	000100	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													5.00	10.00	15.00	5.00	1	1	1		5.00		15.00	5.10	25		25		5.00	10.00	15.00	1	1	1															5.00		25			5.00	25						
S7694	103	0		29	10	S7694_103_0	3	3	Preferred Brand	1	4	000001	1	3	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7										25.00	50.00	75.00	25.00	1	1	1		25.00		75.00	33.40	25		25		25.00	50.00	75.00	1	1	1															25.00		25						25.00	25			
S7694	103	0		29	10	S7694_103_0	3	4	Non-Preferred Brand	1	4	100000	1	1	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7													42.60	30	30	30					43.30	30		30					30	30	30																	30							30			
S7694	103	0		29	10	S7694_103_0	3	1	Preferred Generic	3	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	8.70	59		59		2.00	4.00	6.00	1	1	1															2.00		59			2.00	59				1		
S7694	104	0		29	10	S7694_104_0	3	1	Preferred Generic	3	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	8.70	59		59		2.00	4.00	6.00	1	1	1															2.00		59			2.00	59				1		
S7694	104	0		29	10	S7694_104_0	3	5	Specialty Tier	1	4	010010	1	1	100010010010100000000101				30			30				30									30		34		34	7													444.00	29							443.70	29							29																			29				29			29			
S7694	104	0		29	10	S7694_104_0	3	1	Preferred Generic	1	4	001000	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													2.00	4.00	6.00	2.00	1	1	1		2.00		6.00	3.00	25		25		2.00	4.00	6.00	1	1	1															2.00		25			2.00	25						
S7694	104	0		29	10	S7694_104_0	3	2	Non-Preferred Generic	1	4	000100	1	3	000011110110111000000100				30	60	90	30		90	1	30	60	90							30		34													5.00	10.00	15.00	5.00	1	1	1		5.00		15.00	5.10	25		25		5.00	10.00	15.00	1	1	1															5.00		25			5.00	25						
S7694	104	0		29	10	S7694_104_0	3	3	Preferred Brand	1	4	000001	1	3	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7										25.00	50.00	75.00	25.00	1	1	1		25.00		75.00	33.40	25		25		25.00	50.00	75.00	1	1	1															25.00		25						25.00	25			
S7694	104	0		29	10	S7694_104_0	3	4	Non-Preferred Brand	1	4	100000	1	1	100011110110111000000001				30	60	90	30		90	1	30	60	90							30				34	7													42.60	30	30	30					43.30	30		30					30	30	30																	30							30			
S8067	001	0		29	10	S8067_001_0	5	2	Non-Preferred Generic	1	3	000100		2	010100000010101000000110	31		90							1	31		90							31		31	14				21.00		63.00																						21.00		63.00																		21.00					21.00							
S8067	001	0		29	10	S8067_001_0	5	1	Preferred Generic	1	3	001000		2	010100000010101000000110	31		90							1	31		90							31		31	14				6.00		18.00																						6.00		18.00																		6.00					6.00							
S8067	001	0		29	10	S8067_001_0	5	4	Specialty Tier	1	3	010001		1	110000000010100000000111	31										31									31		31	14	31	14					209.00	33																							33																			33				33			33			
S8067	001	0		29	10	S8067_001_0	5	3	Preferred Brand	1	3	000001		2	110100000010101000000001	31		90							1	31		90							31				31	14		45.00		135.00																						45.00		135.00																		45.00								45.00				
S8067	003	0		29	10	S8067_003_0	5	5	Specialty Tier	1	4	010010	1	1	110000000010100000000111	31										31									31		31	14	31	14					374.00	33																							33																			33				33			33			
S8067	003	0		29	10	S8067_003_0	5	1	Preferred Generic	3	4	001000	1	2	010100000010101000000110	31		90							1	31		90							31		31	14				5.00		15.00																						5.00		15.00																		5.00					5.00					1		
S8067	003	0		29	10	S8067_003_0	5	4	Non-Preferred Brand	1	4	100000	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		85.00		255.00																						85.00		255.00																		85.00								85.00				
S8067	003	0		29	10	S8067_003_0	5	3	Preferred Brand	1	4	000001	1	2	110100000010101000000001	31		90							1	31		90							31				31	14		40.00		120.00																						40.00		120.00																		40.00								40.00				
S8067	003	0		29	10	S8067_003_0	5	2	Non-Preferred Generic	3	4	000100	1	2	010100000010101000000110	31		90							1	31		90							31		31	14				20.00		60.00																						20.00		60.00																		20.00					20.00					1		
S8067	003	0		29	10	S8067_003_0	5	1	Preferred Generic	1	4	001000	1	2	010100000010101000000110	31		90							1	31		90							31		31	14				5.00		15.00																						5.00		15.00																		5.00					5.00							
S8067	003	0		29	10	S8067_003_0	5	2	Non-Preferred Generic	1	4	000100	1	2	010100000010101000000110	31		90							1	31		90							31		31	14				20.00		60.00																						20.00		60.00																		20.00					20.00							
S9014	002	0		29	10	S9014_002_0	2	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				3.00		9.00																								6.00																		3.00					3.00							
S9014	002	0		29	10	S9014_002_0	2	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				10.00		30.00																								20.00																		10.00					10.00							
S9014	002	0		29	10	S9014_002_0	2	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		35.00		105.00																								70.00																		35.00								35.00				
S9014	002	0		29	10	S9014_002_0	2	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							2			90							30				31	14		95.00		285.00																								190.00																		95.00								95.00				
S9014	002	0		29	10	S9014_002_0	2	5	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		31	14	31	14					1045.64	33																							33																			33				33			33			
S9014	002	0		29	10	S9014_002_0	2	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				3.00		9.00																								6.00																		3.00					3.00					1		
S9014	002	0		29	10	S9014_002_0	2	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				10.00		30.00																								20.00																		10.00					10.00					1		
S9014	004	0		29	10	S9014_004_0	2	4	Non-Preferred Brand	1	4	100000	1	2	110100000010001000000001	30		90							2			90							30				31	14		95.00		285.00																								190.00																		95.00								95.00				
S9014	004	0		29	10	S9014_004_0	2	5	Specialty Tier	1	4	010010	1	1	110000000010100000000111	30										30									30		31	14	31	14					813.36	33																							33																			33				33			33			
S9014	004	0		29	10	S9014_004_0	2	1	Preferred Generic	3	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				3.00		9.00																								6.00																		3.00					3.00					1		
S9014	004	0		29	10	S9014_004_0	2	2	Non-Preferred Generic	3	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				10.00		30.00																								20.00																		10.00					10.00					1		
S9014	004	0		29	10	S9014_004_0	2	1	Preferred Generic	1	4	001000	1	2	010100000010001000000110	30		90							1			90							30		31	14				3.00		9.00																								6.00																		3.00					3.00							
S9014	004	0		29	10	S9014_004_0	2	2	Non-Preferred Generic	1	4	000100	1	2	010100000010001000000110	30		90							1			90							30		31	14				10.00		30.00																								20.00																		10.00					10.00							
S9014	004	0		29	10	S9014_004_0	2	3	Preferred Brand	1	4	000001	1	2	110100000010001000000001	30		90							2			90							30				31	14		35.00		105.00																								70.00																		35.00								35.00				
