Your Benefits

Use the table below to find the benefit documents for your WellSense Clarity MA plan. There are three types of benefit documents:

  • The Summary of Benefits is most often used when someone is shopping for a new plan. It offers an overview of how you and the plan you're considering will share the cost for covered healthcare services. 
  • The Schedule of Benefits explains your benefits and cost-sharing (the costs you pay for certain covered services). Cost-sharing consists of deductibles, copayments, and/or coinsurance.
  • The Evidence of Coverage provides the most detail about your health plan. This includes how the plan works, what’s covered, what’s not covered, the cost of services, and much more.  

 

Plan Name Summary of Benefits Schedule of Benefits Evidence of Coverage
ConnectorCare 1 Summary of Benefits
Resumen de beneficios

Schedule of Benefits
Esquema de beneficios

Evidence of Coverage
Evidencia de cobertura
ConnectorCare 2 Summary of Benefits
Resumen de beneficios		 Schedule of Benefits
Esquema de beneficios		 Evidence of Coverage
Evidencia de cobertura
ConnectorCare 3 Summary of Benefits
Resumen de beneficios		 Schedule of Benefits
Esquema de beneficios		 Evidence of Coverage
Evidencia de cobertura
Platinum 0 Deductible
Platinum 0 DeductibleSG		 Summary of Benefits
Resumen de beneficios		 Schedule of Benefits
Esquema de beneficios		 Evidence of Coverage
Evidencia de cobertura
Gold 0 Deductible
Gold 0 DeductibleSG		 Summary of Benefits
Resumen de beneficios		 Schedule of Benefits
Esquema de beneficios		 Evidence of Coverage
Evidencia de cobertura
Gold 1500
Gold 1500SG		 Summary of Benefits
Resumen de beneficios		 Schedule of Benefits
Esquema de beneficios		 Evidence of Coverage
Evidencia de cobertura
Silver 2000
Silver 2000SG		 Summary of Benefits
Resumen de beneficios		 Schedule of Benefits
Esquema de beneficios		 Evidence of Coverage
Evidencia de cobertura
Silver 2000 II  Summary of Benefits
Resumen de beneficios		 Schedule of Benefits
Esquema de beneficios		 Evidence of Coverage
Evidencia de cobertura
Silver 3000
Silver 3000SG		 Summary of Benefits
Resumen de beneficios		 Schedule of Benefits
Esquema de beneficios		 Evidence of Coverage
Evidencia de cobertura
Silver HSA 2000SG Summary of Benefits
Resumen de beneficios		 Schedule of Benefits
Esquema de beneficios		 Evidence of Coverage
Evidencia de cobertura
Bronze HSA 3600
Bronze HSA 3600SG		 Summary of Benefits
Resumen de beneficios		 Schedule of Benefits
Esquema de beneficios		 Evidence of Coverage
Evidencia de cobertura
AI/AN Clarity Summary of Benefits
Resumen de beneficios		 Schedule of Benefits
Esquema de beneficios		 Evidence of Coverage
Evidencia de cobertura

 

Employer Choice Direct plan members please refer to this Evidence of Coverage | Evidencia de cobertura

List of Covered Preventive Care Services

Some procedures or services require prior authorization, or prior approval, from us. You or your doctor can confirm if the service requires a prior authorization. To request a printed copy of any of the benefit documents above, please contact Member Services.

*Please see the current year's Evidence of Coverage and Schedule of Benefits for specific information on each WellSense Clarity plan, or additional information including which benefits, services and medications are covered or non-covered on our plan - and any restrictions or guidelines we must follow before providing them. You can find doctors and hospitals in our network here, see our privacy practices, and learn how we make sure you get the right care at the right time with our Utilization Management policy.