Voyager Essential

IV. How the Plan Works
The Covered Person’s Plan pays a portion of his/her Covered Expenses after he/she meets his/her Deductible for each Trip Coverage Period. This section describes the Deductible and discusses steps to take to ensure that he/she receives the highest level of benefits available under this Certificate of Coverage. See Definitions (Section III) for a definition of Covered Expenses and Covered Services.

The benefits described in the following sections are provided for Covered Expenses incurred by the Covered Person while covered under this Certificate of Coverage. An expense is incurred on the date the Covered Person receives the service or supply for which the charge is made. These benefits are subject to all provisions of this Certificate of Coverage, which may limit benefits or result in benefits not being payable.

Either the Covered Person or the provider of service must claim benefits by sending the Insurer properly completed claim forms itemizing the services or supplies received and the charges.

Benefits
This Benefits section shows the maximum Covered Expense for each type of provider.

No benefits are payable unless the Covered Person’s coverage is in force at the time services are rendered, and the payment of benefits is subject to all the terms, conditions, limitations and exclusions of this Certificate of Coverage.

Hospitals, Physicians, and Other Providers
The amount that will be treated as a Covered Expense for services provided by a Provider will not exceed the lesser of actual billed charges or a Reasonable Charge as determined by the Insurer.

The Covered Person will always be responsible for any expense incurred which is not covered under this Certificate of Coverage.

Deductibles
Deductibles are prescribed amounts of Covered Expenses the Covered Person must pay before benefits are available. The Deductible applies to all Covered Expenses, unless otherwise stated. Only Covered Expenses are applied to the Deductible. Any expenses the Covered Person incurs in addition to Covered Expenses are never applied to any Deductible.

Deductibles will be credited on the Insurer’s files in the order in which the Covered Person’s claims are processed, not necessarily in the order in which he/she receives the service or supply.

If the Covered Person submits a claim for services which have a maximum payment limit and his/her Period of Insurance Deductible is not satisfied, the Insurer will only apply the allowed per visit, per day, or per event amount (whichever applies) toward any applicable Deductible.

Payment
After the Insured Participant satisfies any required Deductible, payment of Covered Expenses is provided as defined in the Benefit Overview Matrix in Section I of this document.

Please note any additional limits on the maximum amount of Covered Expenses in the discussions of each specific benefit.

V. Benefits: What the Plan Pays
Before this Plan pays for any benefits, the Covered Person must satisfy his/her Trip Coverage Period Deductible. After the Covered Person satisfies the Deductible, the Insurer will begin paying for Covered Services as described in this section.

The benefits described in this section will be paid for Covered Expenses incurred on the date the Covered Person receives the service or supply for which the charge is made. These benefits are subject to all terms, conditions, exclusions, and limitations of this Plan. All services are paid at percentages and amounts indicated below or in the Benefit Overview Matrix, and subject to limits outlined in Section IV, How the Plan Works.

Following is a general description of the supplies and services for which the Covered Person’s Plan will pay benefits, if such supplies and services are Medically Necessary:

Services and Supplies Provided by a Hospital
For any eligible condition not excluded under this Certificate including for Mental, Emotional or Functional Nervous Conditions or Disorders, and Substance Abuse, the Insurer will pay indicated benefits on Covered Expenses for:
1. Inpatient services and supplies provided by the Hospital except private room charges above the prevailing two-bed room rate of the facility.

Note: When outside the United States, this benefit will provide coverage for private rooms if that is all that is available or if the choice is between a ward or a more than two person room and a private room.

2. Outpatient services and supplies including those in connection with outpatient surgery performed at an Ambulatory Surgical Center.

3. Emergency Hospitalization and Emergency Medical Care provided in a Hospital emergency room, including professional air and ground ambulance services for transport to and from the Hospital for such Emergency Hospitalization and Emergency Medical Care.

Payment of Inpatient Covered Expenses are subject to these conditions:
1. Services must be those which are regularly provided and billed by the Hospital.

2. Services are provided only for the number of days required to treat the Covered Person’s Illness or Injury

Note: No benefits will be provided for personal items, such as TV, radio, guest trays, etc.

Note: Injuries and Illnesses resulting from Terrorism and pandemics are covered as any other Injury or Illness provided all of the following conditions are met:
1. The Covered Person had no direct or indirect involvement in the Terrorist Activity;

2. The Terrorist Activity or pandemic is not in a country or location where the United States movement has issued a travel warning that has been in effect with the three (3) months prior to the Covered Person’s date of arrival

3. The Covered Person has not unreasonably failed or refused to depart a country or location following the date a warning to leave that country or location is issued by the United State Government.

Professional and Other Services
The Insurer will pay Covered Expenses not excluded under this Certificate for:
1. Services of a Physician.

2. Services of an anesthesiologist or an anesthetist.

3. Outpatient diagnostic radiology and laboratory services.

4. Surgical implants.

5. The first pair of contact lenses or the first pair of eyeglasses when required as a result of a covered eye surgery.

6. Self-Administered injectable drugs.

7. Syringes when dispensed with self-administered injectable drugs (except insulin).

8. Blood transfusions, including blood processing and the cost of un-replaced blood and blood products.

9. Rental or purchase of Durable Medical Equipment and/or supplies that are all of the following:

a. ordered by a Physician;
b. of no further use when medical need ends;
c. usable only by the patient;
d. not primarily for the Covered Person’s comfort or hygiene;
e. not for environmental control;
f. not for exercise; and
g. manufactured specifically for medical use.

Note: Medical equipment and supplies must meet all of the above guidelines in order to be eligible for benefits under this Certificate of Coverage. The fact that a Physician prescribes or orders equipment or supplies does not necessarily qualify the equipment or supply for payment. The Insurer determines whether the item meets these conditions. Rental charges that exceed the reasonable purchase price of the equipment are not covered.

Ambulance Services
The following ambulance services are covered under this Certificate of Coverage:
1. Base charge, mileage and non-reusable supplies of a licensed ambulance company for ground or air service for transportation to and from a Hospital.

2. Monitoring, electrocardiograms (EKGs or ECGs), cardiac defibrillation, cardiopulmonary resuscitation (CPR) and administration of oxygen and intravenous (IV) solutions in connection with ambulance service. An appropriate licensed person must render the services.

The Insurer pays as stated in the Benefit Overview Matrix.

Complications of Pregnancy
Complications of Pregnancy are covered under this Certificate of Coverage as any other medical condition. Benefits for complications of pregnancy shall be provided for all Covered Persons.

Dental Care for an Accidental Injury
Benefits are payable for dental care for an Accidental Injury to natural teeth that occurs while the Covered Person is covered under this Plan, subject to the following:
1. services must be received during the six months following the date of Injury;

2. no benefits are available to replace or repair existing dental prostheses even if damaged in an eligible Accidental Injury; and

3. damage to natural teeth due to chewing or biting is not considered an Accidental Injury under this Certificate of Coverage.

In addition, the Certificate of Coverage provides benefits for up to three days of Inpatient Hospital services when a Hospital stay is ordered by a Physician and a Dentist for dental treatment required due to an unrelated medical condition. The Insurer determines whether the dental treatment could have been safely provided in another setting. Hospital stays for the purpose of administering general anesthesia are not considered Medically Necessary. The Insurer pays as stated in the Benefit Overview Matrix.

Dental Care for Relief of Pain
Benefits are payable for dental care for Relief of Pain to the teeth that occurs while the Covered Person is covered under this Certificate of Coverage. Services must be received while covered during the Trip Coverage Period. The Insurer pays as stated in the Benefit Overview Matrix.

Physical and/or Occupational Therapy/Medicine, Including spinal manipulations and other specified therapies including acupuncture
Charges incurred for the following rehabilitative therapies, if prescribed by a Physician to restore function loss due to an illness or injury covered under this Certificate of Coverage.: physical, occupational, chelation, massage, hearing and cardiac/pulmonary therapy. Additionally, coverage shall also be provided for chiropractic care delivered by a currently licensed chiropractor acting within the scope of his or her practice. The coverage shall include initial diagnosis and clinically appropriate and Medically Necessary services and supplies required to treat the diagnosed disorder, subject to the terms and conditions of the Certificate of Coverage; Acupuncture that treats a covered illness or injury provided by Doctor of Acupuncture.

Therapies excluded under this coverage include, but are not limited to: speech therapy, vocational rehabilitation, behavioral training, gym or swim therapy, dance therapy, marital counseling, legal or financial counseling, biofeedback, neuro-feedback, hypnosis, sleep therapy, employment counseling, back to school, return to work services, work hardening programs, driving safety, and services, training, educational therapy or other non-medical ancillary services for learning disabilities, developmental delays or intellectual disabilities.

These Covered Expenses are Limited as stated in the Benefit Overview Matrix.

Benefits for Claims resulting from downhill skiing and scuba diving
The Insurer will pay Covered Expenses for claims resulting from downhill (alpine) skiing. It will also pay Covered Expenses resulting from scuba diving at a depth of 20 meters or less, provided that the diver is certified by the Professional Association of Diving Instructors (PADI) or the National Association of Underwater Instructors (NAUI), or equivalent governing body, or provided that he/she is diving under the supervision of a certified instructor. These Covered Expenses are Limited as stated in the Benefit Overview Matrix.

VI. Exclusions and Limitations: What the Plan does not pay for

Excluded Services
The Plan does not provide benefits for:
1. Any amounts in excess of maximum amounts of Covered Expenses stated in this Plan.

2. Services not specifically listed in this Plan as Covered Services.

3. Expenses incurred in the Home Country.

4. Services or supplies that are not Medically Necessary as defined by the Insurer.

5. Services or supplies that the Insurer considers to be Experimental or Investigative.

6. Expenses incurred for elective treatment or elective surgery which can safely be done after the Covered Person returns to their Home Country.

7. Services received before the Effective Date of Coverage or during an inpatient stay that began before that Effective Date of Coverage.

8. Services received after coverage ends unless an extension of benefits applies as specifically stated under Extension of Benefits in the ‘Who is Eligible for Coverage’ section of this Plan.

9. Services for which the Covered Person has no legal obligation to pay or for which no charge would be made if he/she did not have a health policy or insurance coverage.

10. Services for any condition for which benefits are recovered or can be recovered, either by adjudication, settlement or otherwise, under any workers’ compensation, employer’s liability law or occupational disease law, even if the Covered Person does not claim those benefits.

11. Treatment or medical services required while traveling against the advice of a Physician, while on a waiting list for a specific treatment, or when traveling for the purpose of obtaining medical treatment.

12. Services related to pregnancy or maternity care other than for complications of pregnancy that may arise during a Trip Coverage Period.

13. Conditions caused by or contributed by (a) The inadvertent release of nuclear energy when government funds are available for treatment of Illness or Injury arising from such release of nuclear energy; (b) A Covered Person participating in the military service of any country; (c) A Covered Person participating in an insurrection, rebellion, or riot; (d) Services received for any condition caused by a Covered Person’s commission of, or attempt to commit a felony or to which a contributing cause was the Covered Person being engaged in an illegal occupation; (e) A Covered Person voluntarily using illegal drugs; intentionally taking over the counter medication not in accordance with recommended dosage and warning instructions; and intentionally misusing prescription drugs.

14. Any services provided by a local, state or federal government agency except when payment under this Plan is expressly required by federal or state law.

15. Professional services received or supplies purchased from the Covered Person, a person who lives in the Covered Person's home or who is related to the Covered Person by blood, marriage or adoption, or the Covered Person’s employer.

16. Inpatient or outpatient services of a private duty nurse.

17. Inpatient room and board charges in connection with a Hospital stay primarily for environmental change, physical therapy or treatment of chronic pain; Custodial Care or rest cures; services provided by a rest home, a home for the aged, a nursing home or any similar facility service.

18. Inpatient room and board charges in connection with a Hospital stay primarily for diagnostic tests which could have been performed safely on an outpatient basis.

19. Dental services, dentures, bridges, crowns, caps or other dental prostheses, extraction of teeth or treatment to the teeth or gums, except as specifically stated under Dental Care for Relief of Pain and/or Dental Care for Accidental Injury in the Benefits section of this Plan.

20. Dental and orthodontic services for Temporomandibular Joint Dysfunction (TMJ).

21. Orthodontic Services, braces and other orthodontic appliances.

22. Dental Implants: Dental materials implanted into or on bone or soft tissue or any associated procedure as part of the implantation or removal of dental implants.

23. Routine hearing tests or hearing aids.

24. Optometric services, eye exercises including orthoptics, eyeglasses, contact lenses, routine eye exams, and routine eye refractions, except as specifically stated in this Plan.

25. An eye surgery solely for the purpose of correcting refractive defects of the eye, such as near-sightedness (myopia), astigmatism and/or farsightedness (presbyopia).

26. Outpatient speech therapy.

27. Any Drugs, medications, or other substances dispensed or administered in any outpatient setting except as specifically stated in this Plan. This includes, but is not limited to, items dispensed by a Physician.

28. Any intentionally self-inflicted Injury or Illness. This exclusion does not apply to the Emergency Medical Evacuation Benefit, to the Repatriation of Mortal Remains Benefit and to the Bedside Visit Benefit.

29. Cosmetic surgery or other services for beautification, including any medical complications that are generally predictable and associated with such services by the organized medical community. This exclusion does not apply to Reconstructive Surgery to restore a bodily function or to correct a deformity caused by Injury or congenital defect of a newborn child, or to Medically Necessary reconstructive surgery performed to restore symmetry incident to a mastectomy.

30. Procedures or treatments to change characteristics of the body to those of the opposite sex. This includes any medical, surgical or psychiatric treatment or study related to sex change.

31. Treatment of sexual dysfunction or inadequacy.

32. All services related to the evaluation or treatment of fertility and/or Infertility, including, but not limited to, all tests, consultations, examinations, medications, invasive, medical, laboratory or surgical procedures including sterilization reversals and In vitro fertilization.

33. Cryopreservation of sperm or eggs.

34. All contraceptive services and supplies, including but not limited to, all consultations, examinations, evaluations, medications, medical, laboratory, devices, or surgical procedures.

35. Orthopedic shoes (except when joined to braces) or shoe inserts, including orthotics.

36. Services primarily for weight reduction or treatment of obesity including morbid obesity, or any care which involves weight reduction as a main method of treatment.

37. Routine physical exams or tests that do not directly treat an actual Illness, Injury or condition, including those required by employment or government authority.

38. Charges by a provider for telephone consultations.

39. Items which are furnished primarily for the Eligible Participant’s personal comfort or convenience (air purifiers, air conditioners, humidifiers, exercise equipment, treadmills, spas, elevators and supplies for hygiene or beautification, etc.).

40. Educational services except as specifically provided or arranged by the Insurer.

41. Nutritional counseling or food supplements.

42. Durable medical equipment not specifically listed as Covered Services in the Covered Services section of this Plan. Excluded durable medical equipment includes, but is not limited to: orthopedic shoes or shoe inserts; air purifiers, air conditioners, humidifiers; exercise equipment, treadmills; spas; elevators; supplies for comfort, hygiene or beautification; disposable sheaths and supplies; correction appliances or support appliances and supplies such as stockings.

43. All infusion therapy, chemotherapy, radiation therapy, hemodialysis together with any associated supplies, Drugs or professional services are excluded.

44. Joint replacement or arthroplasty surgery of any kind.

45. Surgical treatment to the spine, back, or discs of the spine, unless it is the result of an accident that occurred during the Trip Period.

46. Growth Hormone Treatment.

47. Routine foot care including the cutting or removal of corns or calluses; the trimming of nails, routine hygienic care and any service rendered in the absence of localized Illness, Injury or symptoms involving the feet.

48. Charges for which the Insurer are unable to determine the Insurer’s liability because the Eligible Participant or a Covered Person failed, within 90 days, or as soon as reasonably possible to: (a) authorize the Insurer to receive all the medical records and information the Insurer requested; or (b) provide the Insurer with information the Insurer requested regarding the circumstances of the claim or other insurance coverage.

49. Charges for the services of a standby Physician.

50. Charges for animal to human organ transplants.

51. Under the medical treatment benefits, for loss due to or arising from a motor vehicle Accident if the Covered Person operated the vehicle without a proper license in the jurisdiction where the Accident occurred.

52. Loss arising from

a. participating in any intercollegiate/interscholastic sport, contest or competition;

b. participating in any intramural sport competition, contest or competition;

c. participating in any club sport competition, contest or competition;

d. participating in any professional sport, contest or competition;

e. while participating in any practice or condition program for such sport, contest or competition;

f. Racing or speed contests;

g. sky diving, mountaineering (where ropes or climbing gear are customarily used), ultra-light aircraft, parasailing, sailplaning, hang gliding, bungee cord jumping, spelunking, or extreme skiing.

53. Claims arising from loss due to riding in any aircraft except one licensed for the transportation of passengers.

54. Treatment for or arising from sexually transmittable diseases. (This exclusion does not apply to HIV, AIDS, ARC or any derivative or variation.)

55. Under the Accidental Death and Dismemberment provision, for loss of life or dismemberment for or arising from an Accident in the Covered Person's Home Country.

56. Under the Repatriation of Remains Benefit and the Medical Evacuation Benefit provision, for repatriation of remains or medical evacuation of the Covered Accident in the Covered Person's Home Country.

57. Treatment of Congenital Conditions.

58. Whenever coverage provided by this Certificate would be in violation of any U.S. economic or trade sanctions, such coverage shall be null and void.

VII. Prescription Drug Benefits

Pharmacy means a licensed retail pharmacy.

Prescription means a written order issued by a Physician.


What Is Covered
1. Outpatient Drugs and medications that federal and/or State law restrict to sale by Prescription only.

2. Insulin.

3. Insulin syringes prescribed and dispensed for use with insulin.

4. All non-infused compound Prescriptions that contain at least one covered Prescription ingredient.

Conditions of Service
The Drug or medicine must be:
1. Prescribed in writing by a Physician and dispensed within one Period of Insurance of being prescribed, subject to federal or state laws.

2. Approved for use by the Food and Drug Administration.

3. For the direct care and treatment of the Covered Person’s Illness, Injury or condition. Dietary supplements, health aids or drugs for cosmetic purposes are not included.

4. Purchased from a licensed retail Pharmacy or other authorized entity in the country in which purchased.

5. Not excluded under the Prescription Drug Exclusions and Limitations below.

The drug or medicine must not be used while the Covered Person is an inpatient in any facility.

The Prescription must not exceed a 30-day supply or for longer than the Period of Coverage.

Prescription Drug Exclusions and Limitations
Prescription Drug reimbursement is subject to and treated as part of any benefit maximums, limitations on Pre-existing Conditions or any other exclusions or limitations contained in this entire Plan. In addition, reimbursement will not be provided for:
1. Drugs and medications not requiring a Prescription, except insulin.

2. Non-medical substances or items.

3. Contraceptive Drugs and devices prescribed for birth control, even if prescribed for other than contraceptive purposes, Drugs and medications used to induce non-spontaneous abortions.

4. Dietary supplements, cosmetics, health or beauty aids.

5. Any vitamin, mineral, herb or botanical product which is believed to have health benefits, but does not have Food and Drug Administration (FDA) approved indication to treat, diagnose or cure a medical condition.

6. Drugs taken while the Eligible Participant or Eligible Dependents are in a Hospital, Skilled Nursing Facility, rest home, sanitarium, convalescent hospital or similar facility.

7. Any Drug labeled "Caution, limited by federal law to investigational use" or Non-FDA approved investigational Drugs, any Drug or medication prescribed for experimental indications (such as progesterone suppositories).

8. Syringes and/or needles, except those dispensed for use with insulin.

9. Durable medical equipment, devices, appliances and supplies.

10. Immunizing agents, biological sera, blood, blood products or blood plasma.

11. Anti-malarial drugs, unless the Covered Person has been diagnosed with malaria.

12. Oxygen.

13. Professional charges in connection with administering, injecting or dispensing of Drugs.

14. Drugs and medications dispensed or administered in an outpatient setting, including but not limited to outpatient hospital facilities and doctor's offices.

15. Drugs used for cosmetic purposes.

16. Drugs used for the primary purpose of treating infertility.

17. Drugs used for the purpose of treating hair loss.

18. Drugs used for sexual stimulation.

19. Anorexiants or Drugs associated with weight loss.

20. Allergy desensitization products, allergy serum.

21. Drugs for treatment of a condition, Illness, or Injury for which benefits are excluded or limited by a Pre-existing Condition, or other contract limitation.

22. Growth Hormone Treatment.

23. Prescription Drugs with a non-prescription (over the counter) chemical and dose equivalent.