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ISI Protect
Benefits

The ISI Protect is designed for international students studying inside the US, and is available in four levels: Economy, Economy Plus, Business Class, and First Class. Each plan level offers different coverage limits with the Economy plan being the most affordable and the First Class plan being the most comprehensive. Please view the benefits below, and contact us if you need further help with choosing the best plan option for you.


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Benefits Economy Economy Plus Business Class First Class
Maximum Benefit per Insured Person per Certificate Period $200,000 $500,000 $1,000,000 $5,000,000
Maximum Benefit per Injury or Illness per Insured Person $100,000 $250,000 $300,000 $500,000
Eligible Medical Expenses
Deductibles, Co-pays, and Coinsurance All covered Eligible Medical Expenses are subject to Deductible, Co-pays, and Coinsurance unless otherwise indicated.
Deductible $0 $0 $0 $0
Emergency Room Co-Pay $350 $250 $150 $100
Physician Office Co-Pay $100 $75 $50 $25
Student Health Center/Teladoc Co-Pay $35 $25 $10 $5
Urgent Care/Walk-in Clinic Co-Pay $75 $50 $25 $10
Physical Therapy/Chiropractic Care Co-Pay $75 $50 $25 $10
Outpatient Prescription Drugs Co-Pay Not subject to Coinsurance $50 $30 $20 $10
Through the Magellan Rx Network
Coinsurance In-network, Inside the US 80% Coverage up to Maximum Benefit 80% Coverage up to $5,000, then 100% up to Maximum Benefit 100% Coverage up to Maximum Benefit
Coinsurance Out-of-network, inside the US 60% Coverage up to Maximum Benefit 70% Coverage up to Maximum Benefit 80% Coverage up to Maximum Benefit 90% Coverage up to Maximum Benefit
Coinsurance Outside the US 100% Coverage of Eligible Expenses up to the Maximum Benefit
Eligible Medical Expenses
Outpatient and Inpatient Services All covered Eligible Medical Expenses are subject to Deductible, Co-pays, and Coinsurance unless otherwise indicated.
Outpatient Facility Charges Usual, reasonable, and customary charges (URC)
Hospital Room and Board including nursing and Ancillary Services Usual, reasonable, and customary charges (URC)
Intensive Care Unit Usual, reasonable, and customary charges (URC)
Operating, treatment, and/or recovery room Usual, reasonable, and customary charges (URC)
Laboratory Usual, reasonable, and customary charges (URC)
Radiology/X-Rays Usual, reasonable, and customary charges (URC)
Professional Fees by Physician including specialists, surgeons, anesthesiologists Usual, reasonable, and customary charges (URC) Assistant surgeon fees subject to a maximum of 20% of covered primary surgeon fees.
Maternity
Pre-natal, delivery, and post-natal care for a covered pregnancy
No Coverage

In Network: Plan pays 80% to $5,000

Out-of-Network: Plan pays 60% to $5,000

In Network: Plan pays 80% to $10,000

Out-of-Network: Plan pays 60% to $10,000

In Network: Plan pays 80% to Maximum Benefit

Out-of-Network: Plan pays 60% to Maximum Benefit
Routine Care of a Newborn Per covered pregnancy No Coverage $250 $500 $750
Therapeutic Termination of Pregnancy $500 after 90 days of continuous coverage
Dental Treatment Accident — $250 per tooth; maximum of $500 (involving associated face, skull, neck and/or jaw Injury)
Acute Onset of Dental Pain — $100 for palliative care only (Certificate Period must be 30 or more days)
Mental Health Disorders Inpatient URC, up to a maximum of $2,500 URC to a maximum of 30 days
Mental Health Disorders Outpatient Coverage includes drug and alcohol abuse $50 per visit; 1 visit per day and 5 total visits URC to a maximum of 30 visits
All other Eligible Medical Expenses Usual, Reasonable, and Customary (URC)
Eligible Medical Expenses
Features All covered Eligible Medical Expenses are subject to Deductible, Co-pays, and Coinsurance unless otherwise indicated.
Benefit Period 60 days if hospitalized on certificate termination date
Incidental Trip Home 15 days per 90 days of coverage
Pre-Existing Conditions Eligible Medical Expenses No Coverage Covered after 6 months of continuous coverage Covered after 3 months of continuous coverage
Pre-Existing Conditions Medical Evacuation and Repatriation of Remains No Coverage Covered as of Certificate Effective Date
Acute Onset of Pre-Existing Conditions No Coverage $5,000 $15,000 $25,000
Wellness Benefit No Coverage $150 for covered immunizations
Terrorism Usual, Reasonable, and Customary Charges (URC)
COVID-19 including viral mutations Usual, Reasonable, and Customary Charges (URC)
Eligible Transportation Expenses All covered Eligible Transportation Expenses are subject to Deductible, Co-pays, and Coinsurance unless otherwise indicated.
Local Ambulance

Illness: $500 if admitted as inpatient

Injury: $500

Illness: $750 if admitted as inpatient

Injury: $750
Interfacility Ambulance Transfer $500 $750
Emergency Medical Evacuation $50,000 $250,000 $300,000 $500,000
Emergency Reunion $1,000 $3,000 $5,000
Repatriation of Remains $25,000 $50,000
Natural Disaster No Coverage $100 per day; 7 days maximum $250 per day; 7 days maximum
Other Expenses Subject to Deductible, Co-pays, and Coinsurance unless otherwise indicated.
Accidental Death & Dismemberment No Coverage $25,000 Principal Sum (Family Maximum: $250,000)
Not subject to Deductible, Co-pays, and Coinsurance
Personal Liability No Coverage $200,000 Not subject to Deductible, Co-pays, and Coinsurance
School Sports Coverage Injuries sustained while participating in covered School Sports No Coverage $5,000 per injury
Adventure Sports Optional Add-On Subject to Deductible, Co-pays, and Coinsurance unless otherwise indicated.
Adventure Sports Coverage Injuries sustained while participating in covered Adventure Sport Not Available Age 15–49: $50,000 Maximum
Age 50–59: $25,000 Maximum
Age 60–64: $10,000 Maximum
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 HDI Global.


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