New Member FAQ
You Have Health Insurance, Now What?
+ Where's my Well Sense Member ID Card?
You will be receiving your ID card and Welcome Kit in the mail. Remember to bring your ID card to all of your doctors' appointments and whenever you pick up prescriptions.
+ What should I do in an emergency?
In an Emergency (inside or outside the Service Area), you should call 911 or seek care at the nearest Emergency facility. If 911 services are not available in your area, call the local number for Emergency medical services.
Not sure if you need to go to the emergency room? Call our free Nurse Advice Line (866-763-4829) for guidance. Registered nurses are available around the clock to answer your health questions and possibly save you a trip to the hospital or emergency room.
If you are not feeling well and your Primary Care Physician (PCP) is unable to see you, or if it is after business hours, you can ask if another doctor in the practice is able to see you. This can be helpful in situations that do not require an emergency room visit, but may not be able to wait until your PCP is next available.
+ Why do I need to choose a doctor, or Primary Care Physician (PCP)?
You need to choose a doctor for all your routine care. Your doctor, also called a Primary Care Physician or PCP, should be the first person you call when you have medical issues (unless it's an emergency). Your doctor will help you manage your health and send you to specialty doctors or hospitals when needed.
If you don't choose a doctor, one will be assigned to you—but you can change at any time.
+ Are there certain doctors I have to choose from?
Generally, any doctor or hospital that you visit must be chosen from a list of providers who work with Well Sense. They are also called “in-network” providers. Your doctor will refer to you other doctors or hospitals on our approved list to make sure that your medical visit is covered by insurance (there are some exceptions). See a list of doctors and hospitals you can use.
For a complete list of the services covered by Well Sense, read the Covered Services List that came in the mail or find it here. This is the most important document you have, since it tells you what Well Sense will/will not cover.
+ What is a Specialist?
There may be times when you may need to see a Specialist. A Specialist is a healthcare provider who is trained to offer specific, often more detailed, treatments than your PCP. If you think you need to see a Specialist, you should first call your PCP. Your PCP can help you identify your specialty care needs.
+ What does Well Sense cover?
- Visits with a doctor for your routine healthcare
- Visits with specialists (doctors who have extra training in an area of medicine)
- Emergency room visits
- Screenings for diabetes, allergies, heart disease, etc.
- Access to mental health and substance abuse services
- Extras like dental kits, bike helmets and car seats
- Routine eye exam every 12 months
- Transportation to your medical appointments
- Prescriptions for little or no cost
*There are some restrictions and certain services or doctor's visits will need prior written approval before they will be covered. For additional information see the links below.
+ Are there services I need approval for?
Some services and medications need prior approval, or prior authorization, from Well Sense before they will be covered. Your PCP will get this approval for you, which is why it is important that you choose a doctor that you are comfortable with who can get to know your health care needs.
+ If I get a non-covered treatment — or don't get prior approval for a treatment that requires it — will you still cover it?
If you or your PCP did not receive prior approval, Well Sense Health Plan will not pay your doctor for your care or services. Your doctor may hold you responsible for the costs of your treatment.
+ What if I want to see a doctor who doesn't accept Well Sense?
In general, you must get all your healthcare services from Well Sense Health Plan network doctors and providers. The only four exceptions are:
- If you need emergency care (or treatment at the closest emergency room for serious illness or injury in a life-threatening situation)
- If you need urgent care when you are traveling outside our service area
- If you need family planning services
- If Well Sense Health Plan (or Beacon Health Strategies for behavioral health services) gives prior approval, also called prior authorization, for you to get care from an out-of-network provider
+ Do I need to pay for it if I see a doctor or get a service that is not covered?
If you did not receive prior approval, you will be responsible for the costs of your visit, except for the four situations listed above.
+ How do I access Behavioral Health services?
We partner with Beacon Health Strategies to manage Behavioral Health services. Call Beacon for help finding a provider for Behavioral Health services. You can also access their online provider directory here.
- 855-834-5655: Toll-free, 24-hour Behavioral Health telephone line
- 866-727-9441: TTY/TDD for hearing impaired
+ Is there anyone I can call for health advice?
Yes. Call the Nurse Advice Line 866-763-4829 (TTY/TDD) and speak to a registered nurse when your doctor's office is closed or if you have a question about your health. All calls are confidential and you can call anytime, seven days a week.
+ What if I have complicated health needs?
Our Care Management Program can make living with conditions like asthma, diabetes, cancer, or other special health needs easier. Pregnant members can get help through this program too. Call 1-855-833-8119 to see if you or your family members qualify.
+ Are my prescriptions covered?
Like services, some drugs require approval before they will be covered. For a list of drugs covered by Well Sense, search our drug list.
Well Sense covers prescription medications, although there are some limitations.
We also cover some over-the-counter drugs with a prescription from your doctor. See which ones are covered.
+ Can I get rides to my appointments?
Yes, we contract with Coordinated Transportation Solutions (CTS) to manage these services. If you need transportation services, you must contact CTS directly. Call 855-739-4775 toll-free, available 24-hours, seven days a week.
+ Still have questions?
Remember, you can call Well Sense Member Services at 877-957-1300 (TTY/TDD: 711), Monday-Wednesday, 8:00 a.m.- 8:00 p.m., Thursday-Friday, 8:00 a.m.-6:00 p.m., for help with any of the items above and much more.