A screenshot of a form titled "formula Results - By Drug". It is a form for mentor (fentanyl citrate) buccal tablet which is covered for 74% of the lives in New Jersey for all plans at Tiers 1-7. The form is titled "Horizon 2-Tier (bluegrass BlueShield New Jersey)". At the top of the form there is a heading that reads "Full Prescribing Information including Boxed Warning". Below the heading there are three fields - Tier 1 Tier 2 Tier 3 Tier 4 Tier 5 Tier 6 Tier 7 Tier 8 Tier 9 Tier 10 Tier 11 Tier 12 Tier 13 Tier 14 Tier 15 Tier 16 Tier 17 Tier 18 Tier 19 Tier 20 Tier 21 Tier 22 Tier 23 Tier 24 Tier 25 Tier 26 Tier 27 Tier 28 Tier 29 Tier 30 Tier 31 Tier 32 Tier 33 Tier 34 Tier 35 Tier 36 Tier 37 Tier 38 Tier 39 Tier 40 Tier 41 Tier 42 Tier 43 Tier 44 Tier 45 Tier 46 Tier 47 Tier 48 Tier 49 Tier 50 Tier 51 Tier 52 Tier 53 Tier 54 Tier 55 Tier 56 Tier 57 Tier 58 Tier 59 Tier 60 Tier 61 Tier 62 Tier 63 Tier 64 Tier 65 Tier 66 Tier 67 Tier 68 Tier 69 Tier 70 Tier 71 Tier 72 Tier 73 Tier 74 Tier 75 Tier 76 Tier 77 Tier 78 Tier 79 Tier 80 Tier 81 Tier 82 Tier 83 Tier 84 Tier 85 Tier 86 Tier 87 Tier 88 Tier 89 Tier 90 Tier 91 Tier 92 Tier 93 Tier 94 Tier 95 Tier 96 Tier 97 Tier 98 Tier 99 Tier 100 Tier 110 Tier 111 Tier 112 Tier 115 Tier 116 Tier 117 Tier 118 Tier 122 Tier 129 Tier 130 Tier 140 Tier 125 Tier 126 Tier 127 Tier 131 Tier 132 Tier 133 Tier 134 Tier 135 Tier 136 Tier 137 Tier 139 Tier 150 Tier 151 Tier 152 Tier 153 Tier 154 Tier 175 Tier 156 Tier 170 Tier 171 Tier 172 Tier 183 Tier 184 Tier 179 Tier 190 Tier 191 Tier 192 Tier 229 Tier 230 Tier 235 Tier 226 Tier 227 Tier 260 Tier 255 Tier 270 Tier 258 Tier 280 Tier 261 Tier 231 Tier 232 Tier 239 Tier 240 Tier 251 Tier 262 Tier 263 Tier 248 Tier 285 Tier 256 Tier 266 Tier 267 Tier 287 Tier 288

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