WellSense Health Plan

WellSense Clarity NH Silver 5000 + $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: $5,000.00 Family: $10000 Per Person: $5000
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,000.00 Family: $16000 Per Person: $8000

Office Visit

Primary Doctor	CoPay: $40.00 CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: $80.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $40.00 CoInsurance: Not Applicable Covered: Covered
Non Preferred Brand Drugs	CoPay: $80.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered
Generic Drugs	CoPay: $20.00 CoInsurance: Not Applicable Covered: Covered
Specialty Drugs	CoPay: $350.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered
Urgent Care Facility	CoPay: $60.00 CoInsurance: Not Applicable Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: No Charge CoInsurance: Not Applicable Covered: Covered

Vision

Routine Eye Exams for Children

CoPay: $80.00
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 standalone dental plan.
Routine Dental Checkups for Adults	Covered: Not Covered