WellSense Health Plan

WellSense Clarity NH Silver 0 Deductible + $0 Rx List + 24/7 Nurse Advice

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $0.00 Family: $0 Per Person: $0
Combined Medical and Drug Out of Pocket Maximum	Individual: $9,200.00 Family: $18400 Per Person: $9200

Office Visit

Primary Doctor	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: $100.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 40.00% Covered: Covered
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 55.00% Covered: Covered
Generic Drugs	CoPay: Not Applicable CoInsurance: 40.00% Covered: Covered
Specialty Drugs	CoPay: Not Applicable CoInsurance: 55.00% Covered: Covered

Inpatient Coverage

Hospital Services	CoPay: $2500.00 Copay per Day CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Copayment applies only to days 1-3 of each admission
Inpatient Services	CoPay: $2,500.00 CoInsurance: Not Applicable Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: $2,000.00 CoInsurance: Not Applicable Covered: Covered
Urgent Care Facility	CoPay: $60.00 CoInsurance: Not Applicable Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: $2,500.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Copayment applies only to days 1-3 of each admission
Pre and Postnatal Office Visit	CoPay: No Charge CoInsurance: Not Applicable Covered: Covered

Vision

Routine Eye Exams for Children

CoPay: $100.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: This Plan covers a complete eye exam with dilation, as needed.

Major Dental Care

Routine Dental Checkups for Children	Covered: Not Covered Benefit Explanation: Members must purchase a separate dental plan for coverage of routine and non-routine dental services.
Routine Dental Checkups for Adults	Covered: Not Covered