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Important Information <br />Our plans group each medication into a tier. The number of tiers may vary based on the plan you <br />choose. You will need to use your formulary to locate what tier your drug is on to determine how much <br />it will cost you. The amount you pay depends on the drug's tier and what stage of the benefit you have <br />reached. Through this document you will see the "0" symbol. Services with this symbol may require prior <br />authorization from the plan before you receive the services from network providers. If you do not get a <br />prior authorization when required, you may have to pay out -of -network cost-sharing, even though you <br />received services from a network provider. Please contact your doctor or refer to the "Evidence of <br />Coverage (EOC)" for more information about services that require a prior authorization from the plan. <br />3 <br />