Medical and Prescription Plans
Your medical and prescription benefits are designed to support you and your family through every stage of life with quality, affordable healthcare coverage you can trust.
Through the South Central Indiana School Trust, members have access to comprehensive medical care, prescription services, wellness resources and tools that help make managing healthcare simpler and more convenient.
Medical Benefit
Provider: Anthem BlueCross BlueShield
Group # W10955
Member Service: (833) 578-4441
Anthem Sydney App
Health Savings Plan
A Health Savings Account (HSA) is a tax-advantaged savings account that can be used for your health care expenses. Pre-tax money from each paycheck is deposited into your personal HSA account for future use.
If you have a qualified high-deductible insurance plan, an HSA can help protect against your health care costs and limit out-of-pocket expenses.
Preferred Provider Organization
PPO, members enjoy the freedom to see any physician or other health care professional from the network of participating providers, including specialists, without a referral.
With a PPO you will receive the highest level of benefits when you seek care from a contracted network physician, facility or other health care professional. Your out of pocket expense will be significantly less if you access care from “participating” providers. In addition, you do not have to worry about any claim forms or bills.
Coverage Plans
| Benefit | In-Network | Out-of-Network |
|---|---|---|
| Deductible (Single / Family) | $2,300 / $4,600 | $4,800 / $9,600 |
| Out-of-Pocket Maximum (Single / Family) | $5,300 / $7,450 | $15,300 / $21,100 |
| Coinsurance | 20% | 50% |
| Primary Care Visit (PCP) | 20% after deductible | 50% after deductible |
| Specialist Visit | 20% after deductible | 50% after deductible |
| Preventive Care | No charge | 50% after deductible |
| Emergency Room | 20% after deductible | 20% after in-network deductible |
| Inpatient | 20% after deductible | 50% after deductible |
| Outpatient | 20% after deductible | 50% after deductible |
| Rx – Retail (34 day supply) | Generic: 20% after deductible Preferred: 20% after deductible Non-Preferred: 20% after deductible *Specialty: 20% after deductible |
Generic: 50% after deductible Preferred: 50% after deductible Non-Preferred: 50% after deductible *Specialty: 50% after deductible |
| Rx – Mail Order (90 day supply) | Generic: 20% after deductible Preferred: 20% after deductible Non-Preferred: 20% after deductible |
Generic: 50% after deductible Preferred: 50% after deductible Non-Preferred: 50% after deductible |
*Note: Specialty medications must be obtained via ESI’s Specialty Pharmacy, Accredo.
| Benefit | In-Network | Out-of-Network |
|---|---|---|
| Deductible (Single / Family) | $3,300 / $6,600 | $9,300 / $18,600 |
| Out-of-Pocket Maximum (Single / Family) | $6,850 / $13,700 | $19,900 / $39,600 |
| Coinsurance | 30% | 50% |
| Primary Care Visit (PCP) | 30% after deductible | 50% after deductible |
| Specialist Visit | 30% after deductible | 50% after deductible |
| Preventive Care | No charge | 50% after deductible |
| Emergency Room | 30% after deductible | 30% after in-network deductible |
| Inpatient | 30% after deductible | 50% after deductible |
| Outpatient | 30% after deductible | 50% after deductible |
| Rx – Retail | Generic: 30% after deductible Preferred: 30% after deductible Non-Preferred: 30% after deductible *Specialty: 30% after deductible |
Generic: 50% after deductible Preferred: 50% after deductible Non-Preferred: 50% after deductible *Specialty: 50% after deductible |
| Rx – Mail Order (90 days) | Generic: 30% after deductible Preferred: 30% after deductible Non-Preferred: 30% after deductible |
Generic: 50% after deductible Preferred: 50% after deductible Non-Preferred: 50% after deductible |
*Note: Specialty medications must be obtained via ESI’s Specialty Pharmacy, Accredo.
| Benefit | In-Network | Out-of-Network |
|---|---|---|
| Deductible (Single / Family) | $1,800 / $3,600 | $4,800 / $9,600 |
| Out-of-Pocket Maximum (Single / Family) | $3,300 / $6,600 | $9,300 / $18,600 |
| Coinsurance | 20% | 50% |
| Primary Care Visit (PCP) | 20% after deductible | 50% after deductible |
| Specialist Visit | 20% after deductible | 50% after deductible |
| Preventive Care | No charge | 50% after deductible |
| Emergency Room | $500 then 20% | $500 then 20% |
| Inpatient | 20% after deductible | 50% after deductible |
| Outpatient | 20% after deductible | 50% after deductible |
| Rx – Retail (34 day supply) | Generic: $10 after deductible Preferred: $30 after deductible Non-Preferred: $45 after deductible *Specialty: $100 after deductible |
Generic: 50% after deductible ($45 min) Preferred: 50% after deductible ($45 min) Non-Preferred: 50% after deductible ($45 min) *Specialty: 50% after deductible ($45 min) |
| Rx – Mail Order (90 day supply) | Generic: $20 copay after deductible Preferred: $60 copay after deductible Non-Preferred: $90 after deductible |
Generic: N/A Preferred: N/A Non-Preferred: N/A |
*Specialty medications must be obtained via ESI’s Specialty Pharmacy, Accredo.
| Benefit | In-Network | Out-of-Network |
|---|---|---|
| Deductible (Single / Family) | $5,300 / $10,600 | $10,300 / $20,600 |
| Out-of-Pocket Maximum (Single / Family) | $7,150 / $14,300 | $20,300 / $40,600 |
| Coinsurance | 30% | 50% |
| Primary Care Visit (PCP) | 30% after deductible | 50% after deductible |
| Specialist Visit | 30% after deductible | 50% after deductible |
| Preventive Care | No charge | 50% after deductible |
| Emergency Room | $250 then 30% | $250 then 30% |
| Inpatient | 30% after deductible | 50% after deductible |
| Outpatient | 30% after deductible | 50% after deductible |
| Rx – Retail (34 day supply) | Generic: $30 after deductible Preferred: $45 after deductible Non-Preferred: $60 after deductible *Specialty: $100 after deductible |
Generic: 50% after deductible ($45 min) Preferred: 50% after deductible ($45 min) Non-Preferred: 50% after deductible ($45 min) *Specialty: 50% after deductible ($45 min) |
| Rx – Mail Order (90 day supply) | Generic: $60 after deductible Preferred: $90 after deductible Non-Preferred: $120 after deductible |
Generic: N/A Preferred: N/A Non-Preferred: N/A |
*Specialty medications must be obtained via ESI’s Specialty Pharmacy, Accredo.
| Benefit | HSA 2300 Plan | HSA 3300 Plan | PPO 1800 Plan | PPO 5300 Plan | ||||
|---|---|---|---|---|---|---|---|---|
| In-Network | Out-of-Network | In-Network | Out-of-Network | In-Network | Out-of-Network | In-Network | Out-of-Network | |
| Deductible Type | Non-Embedded | Embedded | Embedded | Embedded | ||||
| Deductible – Single | $2,300 | $4,800 | $3,300 | $9,300 | $1,800 | $4,800 | $5,300 | $10,300 |
| Deductible – Family | $4,600 | $9,600 | $6,600 | $18,600 | $3,600 | $9,600 | $10,600 | $20,600 |
| Out-of-Pocket Maximum – Single | $5,300 | $15,300 | $6,850 | $19,900 | $3,300 | $9,300 | $7,150 | $23,000 |
| Out-of-Pocket Maximum – Family | $7,450 | $21,100 | $13,700 | $39,600 | $6,600 | $18,600 | $14,300 | $40,600 |
| Coinsurance | 20% | 50% | 30% | 50% | 20% | 50% | 30% | 50% |
| Preventive Care | No charge | 50% after deductible | No charge | 50% after deductible | No charge | 50% after deductible | No charge | 50% after deductible |
| Office Visits – Primary Care Physician | 20% after deductible | 50% after deductible | 30% after deductible | 50% after deductible | 20% after deductible | 50% after deductible | 30% after deductible | 50% after deductible |
| Office Visits – Specialist | 20% after deductible | 50% after deductible | 30% after deductible | 50% after deductible | 20% after deductible | 50% after deductible | 30% after deductible | 50% after deductible |
| Emergency Room | 20% after deductible | 20% after in-network deductible | 30% after deductible | 30% after in-network deductible | $500 then 20% | $500 then 20% | $250 then 30% | $250 then 30% |
| Inpatient Hospital | 20% after deductible | 50% after deductible | 30% after deductible | 50% after deductible | 20% after deductible | 50% after deductible | 30% after deductible | 50% after deductible |
| Outpatient Hospital | 20% after deductible | 50% after deductible | 30% after deductible | 50% after deductible | 20% after deductible | 50% after deductible | 30% after deductible | 50% after deductible |
| Rx – Retail (34 day supply) | Generic: 20% after deductible Preferred: 20% after deductible Non-Preferred: 20% after deductible *Specialty: 20% after deductible |
Generic: 50% after deductible Preferred: 50% after deductible Non-Preferred: 50% after deductible *Specialty: 50% after deductible |
Generic: 30% after deductible Preferred: 30% after deductible Non-Preferred: 30% after deductible *Specialty: 30% after deductible |
Generic: 50% after deductible Preferred: 50% after deductible Non-Preferred: 50% after deductible *Specialty: 50% after deductible |
Generic: $10 after deductible Preferred: $30 after deductible Non-Preferred: $45 after deductible *Specialty: $100 after deductible |
Generic: 50% after deductible ($45 min) Preferred: 50% after deductible ($45 min) Non-Preferred: 50% after deductible ($45 min) *Specialty: 50% after deductible ($45 min) |
Generic: $30 copay after deductible Preferred: $45 copay after deductible Non-Preferred: $60 copay after deductible *Specialty: $100 copay after deductible |
Generic: 50% after deductible ($45 min) Preferred: 50% after deductible ($45 min) Non-Preferred: 50% after deductible ($45 min) *Specialty: 50% after deductible ($45 min) |
| Rx – Mail Order (90 day supply) | Generic: 20% after deductible Preferred: 20% after deductible Non-Preferred: 20% after deductible Specialty: N/A |
Generic: 50% after deductible Preferred: 50% after deductible Non-Preferred: 50% after deductible Specialty: N/A |
Generic: 30% after deductible Preferred: 30% after deductible Non-Preferred: 30% after deductible Specialty: N/A |
Generic: 50% after deductible Preferred: 50% after deductible Non-Preferred: 50% after deductible Specialty: N/A |
Generic: $20 copay after deductible Preferred: $60 after deductible Non-Preferred: $90 after deductible *Specialty: $90 after deductible |
Generic: N/A Preferred: N/A Non-Preferred: N/A Specialty: N/A |
Generic: $60 after deductible Preferred: $90 after deductible Non-Preferred: $120 after deductible *Specialty: $120 after deductible |
Generic: N/A Preferred: N/A Non-Preferred: N/A Specialty: N/A |
*Note: Specialty medications must be obtained via ESI’s Specialty Pharmacy, Accredo.
Pharmacy Benefit
Rx Provider: OptumRx
Member Service: (855) 524-0381
OptumRx App
- All maintenance medications must be set up on a 90-day Rx fill and be filled through Optum Rx (mail order) or CVS Pharmacy.
- Members need to work directly with their prescribing physician if their current maintenance medication is not set up on a 90-day fill.
- Walgreens is excluded from the covered pharmacy list.
- Non-maintenance medications may be filled at any participating In-Network pharmacy.
Register With Optum Rx
How to Use the Optum Rx App
Optum Rx Formulary Information
Optum Rx Medication Exclusions
CVS Pharmacy Website
Discount Pharmacy: GoodRx
Website: www.goodrx.com
Find the lowest price on prescriptions right from your phone or iPad. The free, easy-to-use mobile app features access to the lowest prices for prescription drugs at more than 75,000 pharmacies and coupons and savings tips.
Additional Benefits
Health and Wellness Clinics
for SCIST members
Our trusted medical provider partners work alongside us to deliver high-quality, affordable healthcare services for employees and their families. Together, we are committed to improving access to care, supporting wellness and helping members navigate their healthcare journey with confidence.