Prescription drug program at a glance

Plan features	HRA Plus		HSA Base		HRA Value
	In-network	Out-of-network	In-network	Out-of-network	In-network	Out-of-network
30-day supply through retail or mail order
Preventive*	No copay	50% after deductible	0%, no deductible	50% after deductible	No copay	50% after deductible
Generic	$15 copay	50% after deductible	20% after deductible	50% after deductible	$15 copay	50% after deductible
Preferred brand	30% up to $125 max	50% after deductible	30% after deductible (up to $125 max)	50% after deductible	30% up to $125 max	50% after deductible
Non-preferred brand	40% up to $225 max	50% after deductible	40% after deductible (up to $225 max)	50% after deductible	40% up to $225 max	50% after deductible
Accredo Specialty Pharmacy
Specialty (limited to a 30-day supply)	40% up to $225 max	50% after deductible	40% after deductible (up to $225 max)	50% after deductible	40% up to $225 max	50% after deductible
90-day supply through retail or mail order** (Note: Mail order is not covered out-of-network.)
Preventive*	No copay	50% after deductible	0%, no deductible	50% after deductible	No copay	50% after deductible
Generic	$37 copay	50% after deductible	20% after deductible	50% after deductible	$37 copay	50% after deductible
Preferred brand	30% up to $312 max	50% after deductible	30% after deductible (up to $312 max)	50% after deductible	30% up to $312 max	50% after deductible
Non-preferred brand	40% up to $562 max	50% after deductible	40% after deductible (up to $562 max)	50% after deductible	40% up to $562 max	50% after deductible

* You can obtain specific preventive medications in-network with reduced cost-share as follows:

There is no cost for medications on Cigna’s No Cost-Share Preventive Medication (ACA) list for all plan participants.

• Additionally, for HSA Base Plan participants, when you purchase other preventive medications listed on Cigna’s Preventive Generics and Preferred Brands Drug list, you will pay 20% coinsurance, but no deductible applies.
• To see Cigna’s lists of preventive medications, visit MyAllscriptsBenefits.com, mycignaplans.com or mycigna.com. For cost details regarding preventive medications and the Value Prescription Drug List, contact Cigna at 1-888-806-5042.

** You must fill maintenance medication prescriptions in a 90-day supply through Cigna 90 Now.

Note: This is a brief summary of the Allscripts associate benefits. Coverage is subject to the insurance policy terms and conditions and government statutes. Allscripts reserves the right to change, suspend or terminate any employee benefit at any time.