Your Benefits | Clarity Plans | WellSense Health Plan

Use the table below to find the benefit documents for your 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

Plan Name	Summary of Benefits	Schedule of Benefits	Evidence of Coverage	Evidencia de cobertura
ConnectorCare I	Summary of Benefits Resumen de beneficios	Schedule of Benefits Esquema de beneficios	Evidence of Coverage	Evidencia de cobertura
ConnectorCare II	Summary of Benefits Resumen de beneficios	Schedule of Benefits Esquema de beneficios	Evidence of Coverage	Evidencia de cobertura
ConnectorCare III	Summary of Benefits Resumen de beneficios	Schedule of Benefits Esquema de beneficios	Evidence of Coverage	Evidencia de cobertura
Platinum	Summary of Benefits Resumen de beneficios	Schedule of Benefits Esquema de beneficios	Individual Group	Para individuos Para grupos
Gold	Summary of Benefits Resumen de beneficios	Schedule of Benefits Esquema de beneficios	Individual Group	Para individuos Para grupos
Low Gold	Summary of Benefits Resumen de beneficios	Schedule of Benefits Esquema de beneficios	Individual Group	Para individuos Para grupos
Silver A	Summary of Benefits Resumen de beneficios	Schedule of Benefits Esquema de beneficios	Individual	Para individuos
Silver A II	Summary of Benefits Resumen de beneficios	Schedule of Benefits Esquema de beneficios	Individual Group	Para individuos Para grupos
Silver B	Summary of Benefits Resumen de beneficios	Schedule of Benefits Esquema de beneficios	Individual	Para individuos
Low Silver	Summary of Benefits Resumen de beneficios	Schedule of Benefits Esquema de beneficios	Group	Para grupos
Bronze	Summary of Benefits Resumen de beneficios	Schedule of Benefits Esquema de beneficios	Individual Group	Para individuos Para grupos
AI/AN Limited Cost-Sharing	Summary of Benefits	Select Network Silver Network Esquema de beneficios (Select) Esquema de beneficios (Silver)	Individual	Para individuos
AI/AN Zero Cost-Sharing	Summary of Benefits	Select Network Silver Network Esquema de beneficios (Select) Esquema de beneficios (Silver)	Individual	Para individuos

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.