Your Benefits

Use the table below to find the benefit documents for your WellSense Clarity plan in Massachusetts. 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, which services require prior authorization, and much more.

Plan Name	Summary of Benefits	Schedule of Benefits	Evidence of Coverage
Platinum 0 Deductible	Summary of Benefits Resumen de beneficios	Schedule of Benefits Esquema de beneficios	Evidence of Coverage Evidencia de cobertura
Platinum 0 DeductibleSG	Summary of Benefits Resumen de beneficios	Schedule of Benefits Esquema de beneficios	Evidence of Coverage Evidencia de cobertura
Gold 1000	Summary of Benefits Resumen de beneficios	Schedule of Benefits Esquema de beneficios	Evidence of Coverage Evidencia de cobertura
Gold 1000SG	Summary of Benefits Resumen de beneficios	Schedule of Benefits Esquema de beneficios	Evidence of Coverage Evidencia de cobertura
Gold 1800	Summary of Benefits Resumen de beneficios	Schedule of Benefits Esquema de beneficios	Evidence of Coverage Evidencia de cobertura
Gold 1800SG	Summary of Benefits Resumen de beneficios	Schedule of Benefits Esquema de beneficios	Evidence of Coverage Evidencia de cobertura
Silver 2000	Summary of Benefits Resumen de beneficios	Schedule of Benefits Esquema de beneficios	Evidence of Coverage Evidencia de cobertura
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 HSA 3000SG	Summary of Benefits Resumen de beneficios	Schedule of Benefits Esquema de beneficios	Evidence of Coverage Evidencia de cobertura
Silver 4000	Summary of Benefits Resumen de beneficios	Schedule of Benefits Esquema de beneficios	Evidence of Coverage Evidencia de cobertura
Silver 4000SG	Summary of Benefits Resumen de beneficios	Schedule of Benefits Esquema de beneficios	Evidence of Coverage Evidencia de cobertura
Silver 7250	Summary of Benefits Resumen de beneficios	Schedule of Benefits Esquema de beneficios	Evidence of Coverage Evidencia de cobertura
Bronze HSA 5000	Summary of Benefits Resumen de beneficios	Schedule of Benefits Esquema de beneficios	Evidence of Coverage Evidencia de cobertura
Bronze HSA 5000SG	Summary of Benefits Resumen de beneficios	Schedule of Benefits Esquema de beneficios	Evidence of Coverage Evidencia de cobertura
ConnectorCare Plan 2	Summary of Benefits Resumen de beneficios	Schedule of Benefits Esquema de beneficios	Evidence of Coverage Evidencia de cobertura
ConnectorCare Plan 3	Summary of Benefits Resumen de beneficios	Schedule of Benefits Esquema de beneficios	Evidence of Coverage Evidencia de cobertura
Catastrophic	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

List of Covered Preventive Care Services

Plan Name	Summary of Benefits	Schedule of Benefits	Evidence of Coverage
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	Summary of Benefits Resumen de beneficios	Schedule of Benefits Esquema de beneficios	Evidence of Coverage Evidencia de cobertura
Platinum 0 DeductibleSG	Summary of Benefits Resumen de beneficios	Schedule of Benefits Esquema de beneficios	Evidence of Coverage Evidencia de cobertura
Gold 1000	Summary of Benefits Resumen de beneficios	Schedule of Benefits Esquema de beneficios	Evidence of Coverage Evidencia de cobertura
Gold 1000SG	Summary of Benefits Resumen de beneficios	Schedule of Benefits Esquema de beneficios	Evidence of Coverage Evidencia de cobertura
Gold 1750	Summary of Benefits Resumen de beneficios	Schedule of Benefits Esquema de beneficios	Evidence of Coverage Evidencia de cobertura
Gold 1750SG	Summary of Benefits Resumen de beneficios	Schedule of Benefits Esquema de beneficios	Evidence of Coverage Evidencia de cobertura
Silver 2000	Summary of Benefits Resumen de beneficios	Schedule of Benefits Esquema de beneficios	Evidence of Coverage Evidencia de cobertura
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 3500	Summary of Benefits Resumen de beneficios	Schedule of Benefits Esquema de beneficios	Evidence of Coverage Evidencia de cobertura
Silver 3500SG	Summary of Benefits Resumen de beneficios	Schedule of Benefits Esquema de beneficios	Evidence of Coverage Evidencia de cobertura
Silver HSA 2500SG	Summary of Benefits Resumen de beneficios	Schedule of Benefits Esquema de beneficios	Evidence of Coverage Evidencia de cobertura
Bronze HSA 3800	Summary of Benefits Resumen de beneficios	Schedule of Benefits Esquema de beneficios	Evidence of Coverage Evidencia de cobertura
Bronze HSA 3800SG	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.