WellSense Clarity NH Silver 0 Deductible + $0 Rx List + 24/7 Nurse Advice
WellSense Health Plan
Plan overview
Medical deductible
Individual: $0
Family: $0
Per Person: $0
Prescription drug deductible
Individual: $0
Family: $0
Per Person: $0
Combined medical and drug out of pocket maximum
Individual: $10250
Family: $20500
Per Person: $10250
Office visit
Primary Doctor
CoPay: $50.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation:
Specialist
CoPay: $100.00
CoInsurance: Not Applicable
Covered: Covered
Prescription drug information
Preferred brand drugs
CoPay: $50.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation:
Non preferred brand drugs
CoPay: Not Applicable
CoInsurance: 45.00%
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation:
Generic drugs
CoPay: $25.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation:
Specialty drugs
CoPay: Not Applicable
CoInsurance: 50.00%
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation:
Inpatient coverage
Hospital services
CoPay: $2000.00 Copay per Day
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Copayment applies only to days 1-3 of each admission
Inpatient services
CoPay: $2,000.00
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
Benefit Explanation:
Maternity
Labor and delivery hospital stay
CoPay: $2,000.00
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
Limit Quantity:
Limit Unit:
Benefit Explanation: This Plan covers a complete eye exam with dilation, as needed.
Major dental care
Routine dental checkups for children
CoPay:
CoInsurance:
Covered: Not Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: Members must purchase a separate dental plan for coverage of routine and non-routine dental services.
Routine dental checkups for adults
CoPay:
CoInsurance:
Covered: Not Covered
Limit Quantity:
Limit Unit:
Benefit Explanation:
These policies have exclusions, limitations, reduction of benefits, terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company (whichever is applicable).