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.
| 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 |
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Eligible Medical Expenses Deductibles, Co-pays, and Coinsurance All covered Eligible Medical Expenses are subject to Deductible, Co-pays, and Coinsurance unless otherwise indicated. |
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| 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 | |||
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Eligible Medical Expenses Outpatient and Inpatient Services All covered Eligible Medical Expenses are subject to Deductible, Co-pays, and Coinsurance unless otherwise indicated. |
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| 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. | |||
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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) |
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| 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) | |||
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Eligible Medical Expenses Features All covered Eligible Medical Expenses are subject to Deductible, Co-pays, and Coinsurance unless otherwise indicated. |
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| 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 |
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| 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 |
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| 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 |
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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.
This plan is underwritten by HDI Global.
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