Benefits in blue: Subject to ISA
Benefits in black: Not subject to ISA
Individual ISA (member shared responsibility amount)
You choose: $5,000 or $10,000
Preventative Care
Not Covered
Telemedicine (Available 24 hours a day)
You pay $0
Primary Care Visit
Not Covered
Prescription Discount Program
Not Eligible
Emergency Room
$300
Specialist Care
(Hospitalization or Out-Patient Surgery)
(Hospitalization or Out-Patient Surgery)
$ 75 Visit fee
In/Out Patient Surgery
Life threatening emergency immediately available
Life threatening emergency immediately available
100% after ISA and up to
Maximum Sharing Limit.
2 month waiting period
Maximum Sharing Limit.
2 month waiting period
Hospitalization
100% after ISA and up to
Maximum Sharing Limit.
Maximum Sharing Limit.
Urgent Care Visit
Not Covered
Lab Testing (In-Patient Only)
You pay 0$ after ISA
X-Rays (In-Patient Only)
(includes MRI & CT Scans)
(includes MRI & CT Scans)
You pay 0$ after MSR
Maximum Limit per Incident
$500,000
Lifetime Maximum Limit
$1,000,000