ISI Protect Insurance | Benefits


Doctor/Hospital Search

Benefits Economy
Certificate Period Maximum $200,000$200k
Maximum Benefit per illness/Injury $100,000$100k
Deductible $0
ER Co-Pay $350
Student Health Center/Teladoc Co-Pay $35 (Coinsurance does not apply)
Physician office Co-Pay $100
Urgent Care/Walk-in Clinic Co-Pay $75
Provider Network Doctor/Hospital Search
Coinsurance
In-network, Inside the US
80% Coverage up to Maximum Benefit
Coinsurance
Out-of-network, inside the US
60% Coverage up to Maximum Benefit
Coinsurance
Outside the US
100% of Eligible Expenses
The following benefits are all subject to the deductible, copays, and coinsurance, unless otherwise stated:
Hospital Room & Board Usual, reasonable, and customary charges
Local Ambulance
Per Injury/Illness if hospitalized as Inpatient
Up to $500
Intensive Care Unit Usual, reasonable, and customary charges
Outpatient Treatment Usual, reasonable, and customary charges
Outpatient Prescription Medication
Not subject to Coinsurance
$50 Co-Pay
Through the Magellan Rx Network
Mental Health
Outpatient
Up to $50 per day; 5 visits maximum
Coverage includes drug and alcohol abuse
Mental Health
Inpatient
Up to $2,500 maximum
Dental Treatment Accident — $250 per tooth; maximum of $500
Onset of pain — $100 maximum (Certificate Period must be 30 or more days)
Therapeutic Termination of Pregnancy $500 Maximum after 90 days of continuous coverage
Outpatient Physical Therapy & Chiropractic Care
Subject to coinsurance
$75 Co-Pay
Terrorism Usual, reasonable, and customary charges
Emergency Medical Evacuation $50,000$50k
Emergency Reunion $1,000
Repatriation of Remains $25,000$25k
COVID-19
including viral mutations
Usual, reasonable, and customary charges
Incidental Trip Home 15 days per 90 days of coverage
Radiology / X-rays / Labortory Usual, reasonable, and customary charges
Professional fees by Physician
including specialists, surgeons, anesthesiologists
Usual, reasonable, and customary charges
assistant surgeon fees subject to a maximum of 20% of covered primary surgeon fees
Operating room, treatment room and/or recovery room Usual, reasonable, and customary charges
Interfacility Ambulance Transfer $500
All other Eligible Medical Expenses Usual, reasonable, and customary charges
Please note: The benefit table listed above is a consolidated version of the full plan benefits. Please view the plan certificate for the full benefits and limitations of the plan. Limits apply to all benefits.

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This plan is underwritten by Lloyd's.


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