1. Drug costs displayed are estimates and may vary based on the specific quantity, strength, and/or dosage of the medication, the order in which prescriptions are purchased, and the pharmacy used. Estimates are based on costs at network pharmacies, which may vary from pharmacy to pharmacy and may also vary during the year. Arkansas Blue Cross and Blue Shield generally does not cover prescriptions at out-of-network pharmacies, except under non-routine circumstances when you cannot reasonably use network pharmacies. Estimates are based on annual usage. Savings for the remainder of this year may be less for individuals enrolling after January 1. Any estimated costs we provide may differ from actual pharmacy costs. The brand-name drug coverage in the coverage gap is subject to agreements between the Centers for Medicare & Medicaid Services (CMS) and drug manufacturers. Not all brand drugs may be discounted. 2. You may be able to get extra help to pay for your prescription drug premiums and costs. To see if you qualify for extra help call: ◦1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day, 7 days a week. 3. Arkansas Blue Cross and Blue Shield is a PFFS and PDP plan with a Medicare contract. Health Advantage is an HMO plan with a Medicare contract. Enrollment in Arkansas Blue Cross and Blue Shield or Health Advantage depends on contract renewal. 4. You must continue to pay your Medicare Part B premium, and Medicare Part A if applicable, if not otherwise paid for by Medicaid or another third party. 5. Arkansas Blue Cross and Blue Shield covers both brand-name drugs and generic drugs. Generic drugs have the same active ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand-name drugs. 6. The plan uses a formulary which is the list of drugs the plan covers. Formulary and non-formulary drugs are subject to change within a contract year. Members are notified at least 60 days in advance when drugs are removed from the formulary. Drug coverage benefits are subject to limitations; these limitations are described in the formulary. 7. The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact Arkansas Blue Cross and Blue Shield.