to obtain certain drugs, including certain specialty a pharmacy designated by us. may have a Pre-Notification requirement or may a higher cost. a non-Network Pharmacy (including a mail order you may be responsible for any amount over the be required to use a lower-cost drug(s) prior to under your policy being av

have a Pre-Notification requirement or may result in a higher cost. Tier 3 - Your Highest-Cost Retail: $50 copay Retail: $50 copay If you use a non-Network Pharmacy (including a mail order Option Mail-Order $125 copay pharmacy), you may be responsible for any amount over the allowed amount. Tier 4 (if appli