Currentwellsense_health_planPolicy 1-855-833-8122

WellSense Clarity New Hampshire Evidence of Coverage

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This document is the Evidence of Coverage (EOC) for the WellSense Clarity health plan offered in New Hampshire, describing member rights, covered and noncovered services, obligations, and plan administration for enrolled members and prospective applicants.

Policy Summary

Payerwellsense_health_plan

PolicyWellSense Clarity New Hampshire Evidence of Coverage

Policy CodePolicy 1-855-833-8122

Change TypeNo material changes

Effective DateJan 1, 2025

Next Review Date

Key ActionCall Member Service at 855-833-8122 to check the status of a utilization review or to request estimated allowed amounts and cost sharing for proposed medically necessary services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

855-833-8122Member Service phone

711TTY/TDD

24/7Nurse Advice Line

24/7Mental health/SUD line

2025Document effective period

Covered Services, Limits, and Conditions

inv-01: Enrollment, network use, renewability, and access

Enrollment, network use, renewability, and access

Members must meet ACA, New Hampshire Insurance Department, CMS, and plan eligibility requirements and enroll by submitting a signed application and paying applicable premiums.

In exchange for premium payment, WellSense agrees to provide the coverage described in the EOC for the premium period.

Members must choose and receive primary care from a network Primary Care Provider (PCP); PCP manages care and arranges referrals as needed.

Members agree to obtain services from network providers except in specified circumstances (emergencies, urgent care outside service area, certain non-network providers in network facilities, rare lack-of-network-expertise with prior authorization, continuity-of-care situations, and special AI/AN rules).

Non-network care requires PCP or plan prior authorization when used because no network provider has required expertise; when authorized, cost-sharing remains at network levels.

The plan is guaranteed renewable annually subject to contract terms; WellSense may cancel or nonrenew for specified reasons (non-payment, move outside service area, material breach/fraud, or changes in law).

Premium rates may change annually but rates are guaranteed for a rating period of at least 12 months.

In an emergency, members are always covered for emergency care without prior authorization or PCP referral; follow emergency instructions (go to nearest facility or call 911) and notify PCP or plan per post-emergency rules.

If emergency care results in inpatient admission to a non-network facility, the member or representative must notify the plan within 2 working days so the plan can manage care and arrange transfer if appropriate.

Members may change PCPs but are limited to three voluntary changes per calendar year; if no PCP selected within 15 days of coverage effective date, the plan assigns one and will provide assistance/finding providers via Member Service and online directory.

inv-03: Coverage criteria and limits (summary)

Coverage and limits are determined by the member's selected benefit package and the Schedule of Benefits. The EOC describes general rules; specific covered services, cost sharing, and limits are listed in the Schedule of Benefits.

Members must consult their Schedule of Benefits to determine covered services, deductible, copayments, coinsurance, out-of-pocket maximums, and provider network for their benefit package.

Benefit limits apply as stated in the Schedule of Benefits; examples include: chiropractor care 12 visits/year; hearing aids one per ear; pediatric vision one pair frames/lenses per year; habilitation and rehabilitation therapies 20 visits/year per therapy type.

Deductible and Rx deductible rules apply as described in the Schedule of Benefits; family and individual rules govern counting toward deductibles and out-of-pocket maximums.

Cost-sharing (deductible, copayment, coinsurance) and estimated allowed amounts provided by Member Service are informational and do not guarantee coverage; coverage depends on meeting EOC rules and member eligibility at date of service.

inv-04: COVERAGE CRITERIA

Coverage rules for network vs non-network care and emergency services.

Care from non-network providers is not covered except in specified circumstances: emergencies, urgent care when outside the service area, certain non-network providers furnishing services in a network facility, rare lack-of-network expertise with PCP/plan prior authorization, continuity-of-care situations, and special AI/AN rules.

Emergency services are covered without prior authorization or PCP referral (includes emergency mental health/SUD); members should go to nearest emergency facility or call 911; crisis resources (988, NH Rapid Response) are available.

Cost-sharing may apply for ER and observation services; ER cost-sharing is waived if admitted immediately as inpatient (inpatient cost-sharing then applies); non-emergency ER use may incur cost-sharing.

If emergency care does not result in admission, member or representative should call the PCP for follow-up; if admitted to a non-network facility after ER, member or representative MUST call the plan within 2 working days so plan can manage care and arrange transfers if appropriate.

If no PCP selected within 15 days of effective date, plan assigns a PCP; members may change PCPs (up to three voluntary changes per calendar year); Member Service and online Provider Directory assist in finding providers.

inv-05: Basic requirements and inpatient coverage

Conditions that must be met for services to be covered and description of inpatient services covered.

To be covered, services and supplies must be medically necessary, described as covered in Chapter 3, received while you are a member, not excluded, consistent with applicable law, and in some cases authorized in advance by a plan authorized reviewer.

Services should be provided by network providers except as described in Chapter 2; lack of required prior authorization for services that need it will result in noncoverage.

Certain inpatient covered services require prior authorization by a plan authorized reviewer; providers must obtain authorization or the plan will not cover the service.

Inpatient acute hospital care is covered for as many days as medically necessary and includes semi‑private room/board (private only when medically necessary), anesthesia, chemo/radiation, physician visits, diagnostics, dialysis, ICU/cardiac care, therapies, surgery, medications, and nursing care.

Continuity-of-care provisions may allow continued coverage when a PCP or specialist leaves the network for active treatment, institutional care, or scheduled non-elective surgery for up to specified periods (prior approval required, provider must accept plan payment and comply with plan requirements).

inv-06: Inpatient Hospital Care

Inpatient hospital care is covered when medically necessary and includes the following services and limits.

Room and board: semi‑private room and board covered; private room covered only when medically necessary.

Clinical services: anesthesia; chemotherapy and radiation therapy; doctor and specialist visits while inpatient; diagnostic tests, lab and imaging; dialysis; intensive/cardiac care; medications while inpatient; nursing; physical, occupational, speech, cardiac and respiratory therapy; surgery.

Related exclusions for inpatient care: private duty nursing, personal items, charges over semiprivate room rate (except medically necessary private room), charges after discharge, rest or custodial care, and charges after membership ends.

inv-07: Bariatric Surgery

Bariatric surgery coverage conditions.

Bariatric surgery is covered when medically necessary and includes preoperative psychiatric screening and counseling, behavior modification, weight loss and exercise regimens, nutritional counseling, and postoperative follow-up.

Member must be at least 18 years of age for bariatric surgery coverage.

inv-08: Reconstructive Surgery and Procedures

Reconstructive surgery coverage and limits.

Medically necessary reconstructive surgery and procedures are covered when required to relieve pain or to improve or restore bodily function impaired by birth defect, accidental injury, disease, or a covered surgical procedure.

Post‑mastectomy services covered include reconstruction of the affected breast, surgery and reconstruction of the other breast for symmetry, prostheses, and treatment of physical complications (including lymphedema); removal of implants covered only for medical complications.

Cosmetic procedures are excluded except as expressly stated (post‑mastectomy coverage described above).

inv-09: Human Organ Transplants

Transplant coverage and exclusions.

Covered transplants include bone marrow, solid organ, and hematopoietic stem cell transplants when member meets plan criteria and applicable legal requirements; member must be approved by the transplant facility and plan authorized reviewer and services must be provided at a network transplant facility.

The plan covers donor search costs through established registries and certain donor charges incurred in donating to a member to the extent not covered by the donor's plan.

Experimental or investigational organ transplants are excluded; donor charges for members donating to nonmembers are excluded.

inv-10: Maternity Care

Maternity and newborn coverage details.

Hospital and delivery services for the mother are covered; inpatient stay covered at least 48 hours after vaginal delivery and 96 hours after cesarean delivery; decisions to shorten stay are made by attending physician and mother, not the plan.

Routine nursery charges and well newborn care are covered up to 31 days after birth; newborn must be enrolled within 60 days to continue coverage beyond 31 days.

No coverage for delivery or pregnancy problems outside the service area after 37 weeks of pregnancy or when provider indicates risk for early delivery.

inv-11: Inpatient Physician and Extended Care

Inpatient professional services and extended care.

Inpatient physician and surgical services (physicians, surgeons, assistant surgeons, anesthesiologists) are covered as part of inpatient stay; cost‑sharing listed in Schedule of Benefits.

Extended care facility coverage (skilled nursing, rehab, chronic hospital) is covered when medically necessary up to Schedule of Benefits limits; includes facility services and DME use while in facility.

If no extended care bed available, plan may arrange for hospital to provide extended care services until bed available; those extra hospital days count toward extended care limits.

Related exclusions for extended care include private duty nursing, personal items, charges over semiprivate room rate (except medically necessary private room), charges after discharge, custodial care, and charges after membership ends.

inv-12: Outpatient Services

Outpatient authorization requirement.

Certain outpatient covered services require prior authorization by a plan authorized reviewer; if provider does not obtain authorization, the plan will not cover the service.

Examples of services that typically require prior authorization include MSK/spine/joint/interventional pain, high‑tech imaging (CT/CTA, MRI/MRA, PET, nuclear cardiac imaging), genetic testing, DME/orthotics, nonemergency transportation, prosthetics, certain home health, hospice, organ transplants, fertility/infertility services, inpatient rehab, and certain pharmacy‑administered or infused drugs; this list may change over time.

Providers and members can call Member Service to check prior authorization status and request approvals; prior authorization determinations are made within legally set timeframes.

inv-13: Abortion

Abortion coverage exceptions.

Termination of pregnancy is covered when the life of the mother is endangered or when the pregnancy is the result of rape or incest.

inv-14: Allergy Services

Allergy services coverage and limits.

Allergy treatment and testing are covered, including allergy injections.

Sensitivity tests are limited to one per calendar year; blood and pulmonary function tests limited to three per calendar year.

inv-15: Ambulance Services

Ambulance services coverage and exclusions.

Covered ambulance services include transfer between inpatient facilities, ground ambulance to nearest facility for emergency medical care, and air ambulance when ground transport cannot be used or is medically necessary; non‑emergency air transport covered when medically necessary for transfer between facilities.

Excluded: transport by taxi or public transportation and transport to/from medical appointments generally excluded except as described.

inv-16: Autism Spectrum Disorder Services

Autism spectrum disorder services.

Coverage includes outpatient office visits, outpatient rehabilitation (PT/OT/speech and social work) when medically necessary, lab and diagnostic tests, outpatient habilitation services as medically necessary, and applied behavior analysis therapy.

inv-17: Breast Examinations

Breast examination coverage.

Breast examinations including MRI and/or ultrasound are covered for preventive, diagnostic and supplemental exams with no cost-sharing except for High Deductible Health Plans where deductibles apply (preventive exams still protected as required).

inv-18: Cardiac Rehabilitation

Cardiac rehabilitation coverage and exclusions.

Cardiac rehabilitation services (exercise, education, counseling) and intensive cardiac rehabilitation programs are covered when medically necessary.

Excluded: fitness/health club fees, maintenance phases that maintain rehabilitated cardiovascular health, and exercise equipment.

inv-19: Chemotherapy and Radiation Therapy

Cancer therapy coverage.

Outpatient chemotherapy and radiation therapy are covered when medically necessary.

inv-20: Chemotherapy and Radiation Therapy (outpatient oncology services)

Outpatient oncology services

Outpatient chemotherapy and radiation therapy are covered.

inv-21: Chiropractic Care

Chiropractic care limit

Chiropractic coverage for musculoskeletal adjustments and spinal manipulations up to 12 visits per calendar year when furnished by a licensed chiropractor.

inv-22: Clinical Trials

Clinical trials routine care coverage

Medically necessary routine care costs related to qualified or approved clinical trials for cancer or life‑threatening conditions are covered when the trial is approved by an authorized agency and coverage is otherwise available under the plan.

inv-23: Dental Services

Limited dental coverage and exceptions

Most dental services are not covered; limited dental coverage applies only as described in Chapter 3.

Medically necessary dental care for accidental injury to sound natural teeth and gums is covered if treatment is sought/provided within 3 months of the injury.

Hospital and anesthesia charges for dental procedures performed in a hospital or outpatient surgical setting are covered for members under age 13 when significant dental, medical, behavioral, or developmental conditions preclude office treatment.

Dental services necessary to prepare the mouth for medical treatments (e.g., radiation, transplants) are covered, including evaluation, x‑rays, extractions (including surgical), and anesthesia.

inv-24: Diabetes Treatment

Diabetes benefits and supply rules

Outpatient diabetes self‑management training and medical nutrition therapy covered when provided by a certified diabetes provider in‑network.

Coverage includes insulin pumps and supplies, infusion devices, needles/syringes, test strips, lancets, blood glucose monitors for home use; some supplies covered through contracted pharmacy; prior approval required for continuous glucose monitors.

Insulin is covered with cost‑sharing per the Schedule of Benefits with a cost‑sharing cap of $30 copayment per 30‑day prescription.

inv-25: Dialysis

Dialysis coverage and exclusions

Coverage includes inpatient dialysis, outpatient dialysis at network hospitals or free‑standing facilities, and home dialysis including related non‑durable supplies and equipment installation/maintenance; plan decides rent vs buy.

If traveling outside the service area, dialysis is covered for up to one month per calendar year with advance arrangements and prior approval obtained by the network provider.

Excluded for home dialysis: costs to get or supply power, water, or waste disposal systems; costs of a person to help with dialysis; home hemodialysis.

inv-26: Durable Medical Equipment (DME)

Durable Medical Equipment rules, covered items, and exclusions

DME must meet durability and medical necessity criteria, be prescribed by a network physician, and be purchased/rented from a network provider; plan decides whether to rent or buy.

Coverage limited to the least costly adequate DME; the plan pays only for the least costly adequate item if member chooses a higher‑cost item; one item of each type is covered (no backups); repair and maintenance covered.

Examples of covered DME include crutches, canes, walkers, wheelchairs, respiratory/oxygen equipment, insulin pumps and supplies, home blood glucose monitors, hospital beds, certain braces, non‑foot orthotics, and breast pumps (preventive benefit).

Excluded DME includes heating pads, comfort items, foot/shoe orthotics (except for severe diabetic foot disease), exercise equipment, bed pans/rails, and equipment for sports or employment purposes.

inv-27: Early Intervention Services

Early intervention services for young children

Early intervention services covered for children through age 2 (up to 36 months) who meet established criteria; no cost sharing.

Covered when provided by network speech‑language pathologists, physical therapists, occupational therapists, or clinical social workers; benefit limits for rehabilitation/habilitation do not apply to early intervention services.

inv-28: Emergency Services

Emergency services coverage and member/provider notification

Emergency services in an emergency room are covered without prior authorization or PCP referral; post‑stabilization services are covered until treating physician determines transfer or discharge appropriate.

Cost‑sharing may apply for ER and observation services; copayments for ER services are waived if admitted immediately as an inpatient (inpatient cost‑sharing then applies); for non‑network ER care plan pays up to allowed amount and member pays applicable cost‑sharing.

If not admitted after emergency care, member or someone acting on their behalf should call the PCP for follow‑up; if admitted as inpatient to a non‑network facility after ER, member or representative MUST call the plan within 2 working days to enable care coordination and transfer planning; provider notice may satisfy this requirement.

If PCP determines transfer to a network facility is appropriate, plan will transfer member; plan will not pay for continued inpatient care at initial non‑network facility after transfer is determined appropriate and arrangements made.

inv-29: Emergency services and post-emergency rules

Emergency services coverage and member responsibilities

Emergency room care is always covered; no prior authorization or PCP referral required; go to nearest emergency facility or call 911.

Post‑stabilization services are covered until treated and stabilized for transfer or discharge.

Emergency room boarding in an acute care hospital in NH is covered for up to 21 calendar days or until discharge, whichever is sooner.

For non‑network inpatient admission after ER, member or representative must call the plan within 2 working days; provider notice counts as satisfying requirement.

If admitted to non‑network and PCP determines transfer appropriate, member will be transferred to a network facility; plan will not pay for inpatient care at initial facility after transfer is determined and arrangements made.

inv-30: Family planning and infertility

Family planning coverage and exclusions

Outpatient family planning services received from network PCP, OB/GYN, NP, or certified midwife are covered (consultations, diagnostic tests, pregnancy testing, birth control counseling, contraceptive monitoring, genetic testing when results affect care, and contraceptives provided during office visit).

Not covered: reversal of voluntary sterilization; services or fees related to using a surrogate; birth control that does not require a prescription (except when given by a network provider during an office visit).

Infertility interventions such as IVF, IUI, AI and services to promote conception are not covered; diagnostic and treatment for underlying causes may be covered per policy.

inv-31: Home health care

Home health care coverage and limits

Home health care covered when member is homebound for medical reasons, PCP orders a home health care plan including part‑time skilled nursing, and a defined medical goal is set by the PCP.

Covered services include part‑time skilled nursing visits as many as medically necessary; part‑time PT/OT/SLP when component of skilled nursing and needed to restore function; medical social work; nutritional consult; home health aide while receiving skilled nursing/rehab; home visits by network physician; inhalation therapy; home infusion therapy; and TPN.

Excluded: custodial care, housekeeping, household repairs, meals, respite care, private duty nursing, personal care attendants, and homemakers.

inv-32: Hearing aids and examinations

Hearing and audiology

Hearing aids covered to the extent required by New Hampshire law: one hearing aid per hearing‑impaired ear, including initial evaluation, fitting, adjustments and supplies (batteries and cleaning fluid not covered).

Audiology examinations and evaluations covered when performed by a PCP or network hearing specialist.

inv-33: Hospice services

Hospice coverage

Hospice services covered for members who are terminally ill (life expectancy ≤6 months certified by network physician) and who agree to a comfort‑focused plan of care; services may be provided at home, outpatient, or short‑term inpatient when medically necessary.

Covered hospice services may include physician services (when unrelated), skilled nursing, social work, medically necessary home health aide visits, respite care, volunteer services, counseling (bereavement for family up to one year), private duty nursing, and personal care attendant services.

Related benefits: DME and prescription drugs are covered under their respective benefits.

inv-34: Maternity services-outpatient

Maternity outpatient services

Outpatient maternity care covers routine prenatal and postpartum exams and tests, childbirth classes, lactation consultations, and services by certified midwives within scope; must be obtained from a network provider who arranges inpatient care as needed.

inv-35: Laboratory, radiology, and outpatient diagnostics

Laboratory and diagnostic imaging

Diagnostic laboratory tests (examples: HgbA1C, urinary microalbumin, lipid profiles, blood lead testing, PFAS/PFC testing) and diagnostic x‑ray/imaging are covered; lead blood testing preventive/follow‑up has no cost‑sharing.

Prior authorization is required for advanced imaging: CT/CTA, MRI/MRA, PET scans, and nuclear cardiac imaging (NCI/NPI).

Histocompatibility testing necessary to establish bone marrow donor suitability is covered per state guidelines.

inv-36: Miscellaneous covered items

Additional covered services and supplies

Long‑term antibiotic therapy for Tick‑Borne Illness is covered when medically necessary and ordered by a licensed physician after evaluation.

Low‑protein foods are covered when ordered by a physician and medically necessary for inherited amino/organic acid disorders.

Medical formulas (non‑prescription enteral formulas) are covered to the extent required by New Hampshire law for specified metabolic and absorption disorders when ordered by a physician.

Medical supplies (ostomy, tracheostomy, catheter, oxygen, insulin pump supplies) are covered when obtained from a network provider; members should call Member Service to confirm coverage and whether an item falls under the prescription drug benefit.

inv-37: Medical formulas

Medical formulas are covered to the extent required by New Hampshire law when ordered and used for specified conditions.

Non‑prescription enteral formulas for home use are covered when ordered by a physician for persons with inherited diseases of amino acids and organic acids.

Enteral formulas for impaired nutrient absorption due to GI disorders (absorptive surface, functional length, or motility) are covered when ordered by a physician.

inv-38: Medical supplies

Medical supplies are covered when obtained from network providers; members should confirm coverage and whether items fall under prescription drug benefit.

Covered medical supplies include ostomy, tracheostomy, catheter, oxygen supplies, and supplies for insulin pumps when obtained from a network provider.

Members should call Member Service to confirm whether a particular supply is covered and whether it is covered under the prescription drug benefit.

inv-39: Mental health and substance use disorder services

Mental health and substance use disorder services are covered medically necessary inpatient, intermediate, and outpatient; managed by Carelon Behavioral Health.

Medically necessary MH and SUD services (inpatient, intermediate, outpatient) are covered and managed by Carelon Behavioral Health; members may go directly to network providers, call Carelon 24/7, call PCP, or use Carelon's website to find providers.

Treatment for Serious Mental Illness and biologically‑based mental disorders (examples: schizophrenia, bipolar, major depression, PTSD, eating disorders, PANS/PANDAS) is covered; PANS/PANDAS treatment may include IVIG when ordered by a physician.

Initial diagnostic and short‑term SUD outpatient visits: 2 visits to determine diagnosis and up to 3 treatment visits each year without prior authorization; other services may require prior authorization.

Excluded mental health/SUD services include psychoanalysis, custodial care, hypnotherapy, developmental testing, massage/relaxation therapies, services for incarcerated members, and long‑term residential treatment among others.

inv-40: Newborn and adoptive children

Newborn and adoptive child services coverage for medically necessary newborn care and certain screenings.

Medically necessary newborn care, treatment of congenital defects and premature birth are covered for 31 days after birth; continued coverage requires enrolling the newborn as a dependent within 60 days.

Newborn hearing screenings and diagnostic CMV evaluation are covered for infants who fail the final newborn hearing screening, with parental agreement to screenings.

inv-41: Nutritional counseling

Nutritional counseling is covered when furnished by registered dieticians or nutritional professionals for disease management.

Nutrition‑related diagnostic, therapeutic and counseling services are covered when provided by a registered dietitian or nutritional professional for disease management, including initial assessment and planned follow‑up visits.

inv-42: Observation services

Observation services are covered for short-term assessment up to a specified time in an acute care facility.

Observation services in an acute care facility are covered for up to 48 hours to determine if admission or discharge is appropriate.

inv-43: Oral surgery

Oral surgery coverage for medically necessary procedures addressing function or pathology.

Medically necessary oral surgery covered includes treatment of cleft lip/palate, orthognathic surgery for jaw function, tumor treatment/biopsy, and incision & drainage of soft tissue infections.

inv-44: Outpatient and related services

Outpatient services including office visits, outpatient surgery, pediatric vision, and podiatry have defined coverage rules.

Outpatient PCP and specialist office visits are covered to evaluate and treat illness or injury; office visits are subject to cost‑sharing and ancillary services during visits may have separate cost‑sharing.

Outpatient surgery performed under anesthesia in a licensed facility with expected same‑day discharge is covered and includes male voluntary sterilizations, therapeutic terminations of pregnancy, and diagnostic procedures.

Pediatric vision (≤18) covers routine and non‑routine vision services and vision hardware per the Schedule of Benefits.

Podiatry: diabetic members receive routine and non‑routine podiatry coverage; other members covered only for non‑routine medically necessary podiatry by network providers.

inv-45: Prescription drugs

Prescription drug program coverage rules, pharmacy channels, and covered drug categories.

Prescription drugs are covered only if on the plan formulary and provided in accordance with pharmacy program rules: legal prescription, prescribed by licensed provider, filled at network pharmacy (with exceptions for emergencies/travel), and medically necessary.

Mail order drugs for certain maintenance medications are provided through Cornerstone Health Solutions (enrollment required); specialty and Tier 4 drugs excluded from mail order.

Covered drug categories include HRT, contraceptives, smoking cessation drugs (with prescription), insulin and supplies, epinephrine auto‑injectors, opioid antagonists, certain oral anti‑cancer meds, PrEP, and MAT medications; maintenance meds covered up to a 90‑day supply at network pharmacies.

Pharmacy programs include Prior Authorization, Quantity Limits, Step Therapy, and Specialty Pharmacy Providers; certain drugs require prior authorization and providers should verify necessary approvals.

Physician may request formulary exceptions with patient‑specific clinical history; approved exceptions treated under specified tiers with corresponding cost‑sharing; reimbursement processes exist if member pays up front for a previously authorized drug.

inv-46: Prescription Drug Coverage Criteria

Prescription drug coverage, exceptions, and program rules

Covered prescription categories include hormone replacement therapy, contraceptives, smoking cessation drugs (with valid prescription), insulin and supplies, hypodermic syringes when medically necessary, certain compounded medications meeting criteria, epinephrine auto‑injectors, opioid antagonists, oral anti‑cancer meds, PrEP, and MAT medications.

Maintenance medications covered up to a 90‑day supply at network pharmacies; certain early refill rules apply to specified products (e.g., eye drop refill timing rules).

Exclusions include experimental/investigational drugs, drugs not FDA‑approved, drugs for cosmetic or non‑medical purposes, certain compounded meds not meeting active‑ingredient requirements, prescriptions by non‑network providers (except emergencies), non‑network pharmacy fills (except emergencies), and other categories listed in the EOC.

Pharmacy management programs used: Prior Authorization (for very expensive, brand when generic available, new‑to‑market drugs), Quantity Limits, Step Therapy, and Specialty Pharmacy requirements.

Exception Request Process: prescriber may request formulary exceptions with patient‑specific clinical history; exceptions considered for medical necessity and, if approved, are assigned appropriate cost‑sharing tiers; plan provides instructions for reimbursement if member paid up front.

inv-47: Preventive Services

Preventive health services coverage

Preventive health services are covered when provided in accordance with plan medical policy and applicable laws; comprehensive listings available in the EOC or online.

Pediatric preventive schedule and screenings from birth through early childhood are covered per the listed intervals; newborn screenings included.

Adult preventive services and immunizations per ACIP, annual physical once per calendar year, and preventive screenings (e.g., colonoscopy) are covered; no cost‑sharing applies to covered preventive services though associated routine tests or follow‑up care may incur cost‑sharing.

inv-48: Prosthetic Devices

Prosthetic devices coverage and limits

Medically necessary prosthetic devices prescribed by a network physician and purchased from a network provider are covered; devices must meet durability, medical purpose, home use, necessity and fit criteria.

One item of each type of prosthetic device that meets member's needs is covered; plan pays for the least costly adequate device and member may pay excess if choosing a more expensive device; repair and maintenance covered; no annual limits on medically necessary prosthetics.

Activity‑related prosthetics covered for members under 19 who are NH residents, limited to one activity‑specific prosthetic device per plan year.

Exclusions include electronic and myoelectric artificial limbs and wigs when hair loss is due to pattern baldness or aging.

inv-49: Rehabilitation Therapies (Outpatient)

Rehabilitation and related exclusions

Outpatient short‑term physical, occupational, and pulmonary rehabilitative/habilitative therapies are covered when medically necessary to improve ADLs or restore function and are likely to result in significant improvement within the benefit period; subject to Schedule of Benefits limits with exceptions for ASD and early intervention.

Excluded: vocational rehabilitation, educational services/testing, massage therapy, school‑based speech/language/hearing treatment, and sensory integrative testing.

inv-50: Second Opinions

Second opinions

Second opinions by network providers regarding necessity of a covered service are covered; non‑network second opinions covered only when specific expertise unavailable in‑network; third surgical opinions covered when first and second differ.

inv-51: Smoking and Tobacco Cessation

Smoking and tobacco cessation

Individual and group counseling services for tobacco cessation are covered; related prescription drugs are covered under the Prescription Drug benefit.

inv-52: Speech-Language and Hearing Disorder Services

Speech-language and hearing services

Diagnosis and treatment of speech, hearing and language disorders are covered when medically necessary and provided by network speech‑language pathologists and audiologists; benefit limits in Schedule of Benefits.

Diagnosis or treatment in a school‑based setting is excluded.

inv-53: Telemedicine Virtual Visit Services

Telemedicine

Telemedicine virtual visit services are covered with cost‑sharing no greater than equivalent in‑person services and subject to the same deductible and out‑of‑pocket maximum; the plan will not deny services solely because they were provided via telemedicine.

Available modalities include two‑way live audio/video, asynchronous image/video, and other state/federal‑authorized methods; prior authorization may apply to some telemedicine services.

inv-54: Speech-Language and Hearing

Speech-Language and Hearing Disorder Services are covered when medically necessary and provided by network speech-language pathologists and audiologists; benefit limits per Schedule of Benefits.

Coverage for diagnosis and treatment of speech‑language and hearing disorders when medically necessary by network providers; see Schedule of Benefits for limits.

inv-55: Telemedicine

Telemedicine virtual visit services are covered with parity to in-person cost sharing; subject to same deductible and out-of-pocket limits; some telemedicine may require prior authorization.

Telemedicine services receive parity with in‑person cost‑sharing and apply to the same deductibles and MOOP; prior authorization may apply to some telemedicine services; plan will not deny care solely because delivered via telemedicine.

inv-56: Temporomandibular Joint (TMJ) Disorder

TMJ disorder coverage rules.

TMJ disorder treatment is covered only when caused by or resulting from a specific medical condition proven by diagnostic x‑rays or other accepted diagnostic procedures; coverage may require prior authorization.

TMJ syndrome and TMJ disorders not proven to be caused by a specific medical condition are excluded; appliances other than a mandibular orthopedic repositioning appliance (MORA) are excluded.

inv-57: Urgent Care

Urgent care coverage.

Urgent care services are covered for members inside the service area for urgent non‑life‑threatening conditions and for unexpected illness or injury outside the service area.

inv-58: Vision Services

Vision services: pediatric preventive exams, routine and non-routine exams (children), certain medically necessary vision therapies, limited eyewear coverage under specified conditions, pediatric eyeglasses/contact lenses one pair per year until age 19, and visual aids for legal blindness.

Preventive eye exams for children are covered up to the benefit limit; routine and non‑routine exams and treatment for children are covered by network optometrist/ophthalmologist (includes diabetic retinal exams).

Medically necessary vision therapy covered for specified diagnoses (accommodative insufficiency, amblyopia, convergence insufficiency, acquired esotropia prior to surgery).

Contact lenses or eyeglasses (one pair per prescription change) covered in specific medical conditions (post‑op cataract, keratoconus, anisometropia >3.00D, >7.00D myopia/hyperopia); pediatric eyewear: one pair per calendar year until end of month member turns 19.

Routine and preventive eye exams for adults are not covered.

inv-59: Exclusions from Covered Services

Extensive exclusions apply; services not listed as covered are excluded and many specific therapies, devices, procedures, and settings are not covered.

Services not described as covered in the EOC are excluded.

Services related to or furnished with a non‑covered service are excluded except as expressly stated.

Services that are not medically necessary are not covered except limited statutory exceptions (therapeutic termination of pregnancy, voluntary sterilization, prescription contraceptives, covered preventive services).

A broad list of specific exclusions is provided (acupuncture, most biofeedback, hypnotherapy, massage, cosmetic services, concierge fees, many dental services, experimental/investigational treatments except clinical trials, infertility services as enumerated, many behavioral health services, private duty nursing except hospice, personal comfort items, and others).

Replacement/repair exclusions for DME/prosthetics due to loss, intentional damage, negligence, or theft; many assistive technology and adaptive equipment items excluded; drugs and devices excluded per Prescription Drugs section.

Codes, Prior Authorization Categories, and Limits

Cornerstone Mail Order Contactmixed

844-319-7588	Cornerstone Health Solutions mail order phone contact (enrollment required)
781-805-8221	Cornerstone Health Solutions fax for prescriptions
cornerstonehealthsolutions.org/chs-mail-order-pharmacy	Cornerstone mail-order pharmacy website for enrollment and refills

Mail Order Enrollment Notemixed

Enrollment with Cornerstone Health Solutions required to use mail order; certain maintenance drugs only

None in this segmentmixed

No codes listed

Not applicablemixed

No codes listed

Not applicablemixed

No codes listed

No billing or coding listedmixed

No codes listed

Services Subject to Prior Authorization (categories)mixed

MSK	Musculoskeletal services (spine, joint, interventional pain)
High-tech imaging	CT/CTA, MRI/MRA, PET, nuclear cardiac imaging (NCI/NPI)
Genetic Testing	Genetic testing (lab management)
DME/Orthotics	Durable medical equipment and orthotics
Nonemergency transportation	Covered nonemergency transportation
Prosthetics	Prosthetic devices
Low protein food	Low protein food
Medical formulas	Medical formulas
Home health care	Home health care services
Infertility treatment	Infertility treatment

1–10 of 19

1/2

Covered DME and Diabetes Supply ExamplesmixedCovered

Crutches/Canes/Walkers	Crutches, canes, walkers (covered DME)
Wheelchairs	Wheelchairs (covered DME)
Respiratory/Oxygen Equipment	Respiratory and oxygen equipment (covered DME)
Insulin pumps	Insulin pumps and insulin pump supplies (covered DME)
Blood glucose monitors	Home use blood glucose monitors (covered DME)
Test strips and lancets	Diabetic test strips and lancets (covered supplies)
Insulin/needles/syringes	Insulin, insulin needles and syringes (covered under prescription benefit)
Continuous glucose monitors	Continuous glucose monitors and supplies (prior approval required)
Breast pumps	Breast pumps and related supplies (covered under preventive benefit)

Advanced Imaging Prior Authorization Examplesmixed

CT/CTA	CT/CTA scans (prior authorization required)
MRI/MRA	MRI/MRA scans (prior authorization required)
PET	PET scans (prior authorization required)
NCI/NPI	Nuclear cardiac imaging (NCI/NPI) (prior authorization required)

Prescription Drug CategoriesmixedCovered

HRT	Hormone replacement therapy for peri- and post-menopausal women
Contraceptives	Oral and other prescription contraceptives (birth control drugs)
Smoking cessation drugs	Drugs to stop smoking and treat tobacco addiction (prescription required)
Insulin and supplies	Insulin; insulin pens, needles, syringes; blood glucose, urine glucose and ketone monitoring strips; lancets; oral diabetes medications (with prescription)
Hypodermic syringes	Hypodermic syringes or needles when medically necessary
Compounded medications	Certain compounded medications meeting active-ingredient and coverage criteria
Maintenance medications	Maintenance medications (covered up to 90-day supply at network pharmacies)
Epinephrine auto-injectors	Epinephrine auto-injectors
Opioid antagonists	Opioid antagonist medications
Oral anti-cancer meds	Orally administered anti-cancer medications (cost-sharing may not apply to certain meds)

1–10 of 12

1/2

No billing/coding lists in this excerptmixed

Mail order process described; Tier 4 and Specialty excluded from mail order; contact Cornerstone for enrollment and refills

N/A

N/ANot applicable in this section; no numeric thresholds provided.

Document referenceSee Table of Contents for chapter and page references.

UsePlaceholder entry indicating no coding thresholds in this segment.

Document navigation

Primary TOC pages referencedTable of Contents entries reference key chapters and pages (examples: Chapters 3–8; pages cited include 19–72).

Navigation adviceUse the Table of Contents to locate sections such as Prescription Drug Exception Requests (p.37) and Exclusions from Covered Services (p.42).

Where to get updatesOnline EOC or Member Service can confirm current page references and chapter locations.

Prior authorization decision timeframe for court-ordered minor services

Decision timeframeDetermination must be made as soon as possible and no later than 48 hours after receipt of a complete request for court-ordered services for minors.

Request timingProvider, member, or representative must request prior authorization within 48 hours of the effective date of the court-ordered service, placement, or program.

Requests needing more infoIf more information is needed, plan will contact requester within 24 hours and allow at least 48 hours to provide additional information; determination then due within 48 hours after receipt of that information or end of the allotted time period, whichever is earlier.

DME quantity limit

Quantity limitOne item of each type of DME that meets the member's needs; no backup or duplicate items are covered.

Cost responsibilityIf member chooses a higher-cost item than the least costly adequate DME, plan pays only the amount for the least costly adequate item and member may be balance-billed for the difference.

Repair and maintenanceRepair and maintenance of covered DME are included under the benefit.

Hearing aid quantity

Hearing aid quantityCoverage provided for one hearing aid for each hearing-impaired ear, as required by New Hampshire law.

Included servicesCoverage includes initial evaluation, fitting, adjustments, and related supplies such as ear molds (batteries and cleaning fluid not covered).

Provider requirementServices must be prescribed/prescribed by a licensed audiologist or hearing instrument specialist.

Maintenance medication supply limit

Maintenance medication supply limitMaintenance medications are covered up to a 90-day supply at network pharmacies.

Where to fillMaintenance medications should be filled at network pharmacies; mail-order options available for certain maintenance drugs (Cornerstone) with enrollment required.

Formulary/Program rulesCoverage subject to formulary, Pharmacy Programs (prior authorization, quantity limits, step therapy) and other program rules.

Early refill timing for eye drops (30-day supply)

Early refill timing (30-day supply)For prescription eye drops dispensed as a 30-day supply, early refill allowed no earlier than 21 days after the later of the original dispense date or the most recent refill date, subject to other conditions.

ConditionsPrescriber must have indicated authorized refills, request must not exceed authorized refill count, and the prescription must be a covered benefit.

LimitationsPrescription must not have been refilled more than once during the 30-day period prior to the early refill request.

Early refill timing for eye drops (90-day supply)

Early refill timing (90-day supply)For prescription eye drops dispensed as a 90-day supply, early refill allowed no earlier than 63 days after the later of the original dispense date or the most recent refill date, subject to other conditions.

ConditionsPrescriber must have indicated authorized refills, request must not exceed authorized refill count, and the prescription must be a covered benefit.

LimitationsPrescription must not have been refilled more than once during the 90-day period prior to the early refill request.

What Providers and Members Must Do

Documentation Required

Utilization Review Inquiry

Call Member Service to find out the status of a utilization (medical necessity) review decision.

Note

Primary Care Provider contact for routine and urgent care

For preventive, routine, non‑routine, and urgent care inside the service area, always call the member's Primary Care Provider (PCP) to obtain and coordinate care.

Documentation Required

DME/Prosthetics/Orthotics access

Contact Member Service or your PCP; the plan contracts with Northwood, Inc. to manage most durable medical equipment, prosthetics, orthotics, and related supplies.

Documentation Required

Pharmacy benefits manager contact

Contact Member Service or Express Scripts for prescription drug benefit questions; Express Scripts is the plan's pharmacy benefits manager.

Documentation Required

Mail order pharmacy enrollment and refill process

Enroll with Cornerstone Health Solutions to use mail‑order maintenance drugs; providers may call or fax prescriptions to Cornerstone and members can refill by mail, phone, or online after enrollment.

Cornerstone phone: 844-319-7588; fax: 781-805-8221
Enroll via the mail order form in the welcome packet or at cornerstonehealthsolutions.org/chs-mail-order-pharmacy

Documentation Required

Behavioral health/SUD network management

Behavioral health and substance use disorder services are managed by Carelon Behavioral Health; providers and members should contact Carelon or the 24‑hour mental health/SUD line to find network providers or confirm authorization requirements.

Carelon 24‑hour line: 877-957-5600
Crisis support: 988 and NH Rapid Response resources

Prior Authorization

Emergency care instructions

In an emergency, seek care at the nearest emergency facility and call 911 (or the local emergency number if 911 is unavailable).

Note

Table of Contents — no authorization details

The Table of Contents lists sections such as Prescription Drug Exception Requests and Exclusions from Covered Services but does not provide authorization rules in this excerpt.

Note

Table of Contents (partial)

Partial Table of Contents entries list major chapters (for example, CHAPTER 4: Eligibility/Enrollment; CHAPTER 5: Member Satisfaction; CHAPTER 6: When You Have Other Coverage; CHAPTER 7: Plan Administration; CHAPTER 8: Fraud/Privacy) but do not include authorization specifics here.

Note

Table of Contents — Chapters and headings

Table of Contents entries include coverage, plan administration, privacy practices, PHI uses/disclosures, and special protections headings; no prior authorization rules are shown in this excerpt.

Note

Table of contents

This excerpt contains only the Table of Contents and does not include authorization rules or requirements.

Documentation Required

Cost/coverage estimate request

Members or providers may call Member Service at 855-833-8122 or request an estimate on wellsense.org for the estimated allowed amount and estimated member cost sharing for a proposed medically necessary service; estimates do not guarantee coverage.

Estimates are based on available information and coverage depends on meeting all EOC rules and member eligibility on date of service.

Prior Authorization

Non-network provider prior authorization

If no network provider has the professional expertise required, the PCP or plan may arrange non‑network care but the PCP must first obtain prior authorization from a plan authorized reviewer.

If authorized, applicable cost‑sharing remains at network levels.

Prior Authorization

Prior authorization overview and contact

Certain inpatient and outpatient services require prior authorization from a plan authorized reviewer; network providers will request authorization and determinations are made within legally set timeframes—call 855‑833‑8122 to check status.

If authorization is not obtained, the plan will not cover the service.

Prior Authorization

Examples of services requiring prior authorization

Examples of services that typically require prior authorization include musculoskeletal (spine/joint/interventional pain), high‑tech imaging (CT/CTA, MRI/MRA, PET, nuclear cardiac imaging), genetic testing, DME/orthotics, prosthetics, home health care, certain pharmacy‑administered or infused/injected drugs, organ transplants, inpatient rehab and other items listed in the EOC.

Prior Authorization

Prior authorization timing for court-ordered services (minors)

For court‑ordered services for minors that require prior authorization, the provider, member, or representative must request authorization within 48 hours of the effective date; the plan will make a determination as soon as possible and no later than 48 hours after receipt if all necessary information is provided, with specified timelines if additional information is needed.

Prior Authorization

Outpatient prior authorization requirement

Certain outpatient covered services require prior authorization by a plan authorized reviewer; services performed without required authorization will not be covered.

Prior Authorization

Dialysis prior approval for out-of-area travel

If a member travels outside the service area and needs dialysis, the member must make advance arrangements with their network provider and the network provider must obtain prior approval from a plan authorized reviewer; coverage for travel dialysis is limited to up to one month per calendar year.

When Medicare is primary, the member must apply for Medicare; plan covers costs exceeding Medicare when applicable.

Documentation Required

Post-emergency inpatient notice requirement

If admitted as an inpatient to a non‑network facility after emergency care, the member or someone acting on their behalf must call the plan within 2 working days of admission so the plan can manage and coordinate care; notice by the provider to the PCP, plan, or Carelon satisfies this requirement.

Prior Authorization

Continuous glucose monitor prior approval

Prior approval is required for coverage of continuous glucose monitors and for continuous glucose monitor supplies when those supplies are covered through a contracted pharmacy.

Prior Authorization

Prior authorization for advanced imaging

Prior authorization is required for advanced imaging tests including CT/CTA, MRI/MRA, PET scans, and nuclear cardiac imaging (NCI/NPI).

Documentation Required

Post-emergency inpatient notice requirement (repeat)

If admitted as an inpatient to a non‑network facility after emergency care, the member or someone acting on their behalf MUST call the plan within 2 working days of admission to enable care coordination and transfer arrangements; provider notice may satisfy this requirement.

Documentation Required

Home health care ordering

The PCP must order a home health care services plan that includes part‑time skilled nursing and define a medical goal the PCP reasonably expects the member will meet; homebound status and PCP order are required for coverage.

Covered services include part‑time skilled nursing, part‑time PT/OT/SLP when a component of skilled nursing, medical social work, nutritional consult, home health aide while receiving skilled nursing, home visits by a network physician, inhalation therapy, home infusion therapy, and TPN.

Prior Authorization

Mental health/substance use prior authorization rules

Certain mental health and substance use disorder services require prior authorization by a plan authorized reviewer; no prior authorization is required for short‑term inpatient withdrawal management or the first two routine outpatient SUD visits, though other SUD services may require prior authorization—providers should check with Carelon.

Contact Carelon at 877-957-5600 to confirm authorization requirements.

Prior Authorization

Pharmacy prior authorization

Coverage for certain prescription drugs is subject to prior authorization by a plan authorized reviewer; providers must confirm necessary plan approvals have been obtained before prescribing.

Pharmacy programs include Prior Authorization, Quantity Limits, Step Therapy, and Specialty Pharmacy requirements.

Prior Authorization

Prior Authorization for Certain Drugs

Prescribers must obtain prior authorization for certain drugs (including very expensive drugs, brand drugs when a generic is available, and new‑to‑market drugs) from a plan authorized reviewer before coverage will be approved.

Documentation Required

Exception Request Process

If a physician believes a non‑formulary or restricted drug is medically necessary, they may request an exception from a plan authorized reviewer by submitting patient‑specific clinical history; approved exceptions will be considered and covered accordingly.

If a member pays up front for a previously authorized drug, Member Service will provide instructions for reimbursement.

Prior Authorization

Telemedicine Prior Authorization Note

Prior authorization may apply to telemedicine virtual visit services; providers should verify authorization requirements for telemedicine encounters.

Prior Authorization

TMJ prior authorization

Coverage for TMJ disorder treatment may require prior authorization by a plan authorized reviewer; always check with the provider to ensure necessary plan approval has been obtained.

Prior Authorization

Telemedicine prior authorization note (repeat)

Prior authorization may apply for telemedicine virtual visit services—verify prior authorization requirements before scheduling telemedicine visits.

Key Terms and Definitions

Primary Care Provider (PCP)

DefinitionPrimary Care Provider (PCP): a network doctor, physician assistant, or nurse practitioner who provides routine, nonroutine and preventive care and coordinates referrals, selected at enrollment.

Selection timingIf no PCP is selected within 15 days of coverage effective date, the plan may assign one based on zip code and other records.

AvailabilityPCPs or their covering providers are available 24 hours a day.

Evidence of Coverage (EOC)

DefinitionEvidence of Coverage (EOC): the legal contract between the member and WellSense that describes rights, obligations, covered and noncovered services, and the Schedule of Benefits.

ContentsIncludes Schedule of Benefits, cost-sharing amounts, and Definitions; italicized terms are explained in Appendix A.

GuidanceMembers are advised to read and save the EOC; use the Table of Contents to locate needed information.

Behavioral health/SUD manager

Vendor/ManagerCarelon Behavioral Health manages all mental health and substance use disorder services for the plan.

Access optionsMembers may call Carelon's 24-hour line (877-957-5600), call their PCP, go directly to a network provider, or use Carelon's website via wellsense.org.

Crisis resourcesFor immediate crisis or suicide risk, members can call/text/chat 988 or the NH Rapid Response Access Point (1-833-710-6477).

Pharmacy benefits manager

Vendor/ManagerExpress Scripts is the plan's pharmacy benefits manager responsible for administering the prescription drug benefit.

ContactMembers may contact Member Service at 855-833-8122 or contact Express Scripts directly for pharmacy benefit questions; Express Scripts customer service available 24/7.

RoleManages formulary, prior authorization, quantity limits, step therapy, and specialty pharmacy arrangements in coordination with the plan.

Mail order pharmacy contractor

ContractorCornerstone Health Solutions provides the plan's mail order pharmacy services for certain maintenance drugs; enrollment is required.

How to enrollMembers enroll by calling Cornerstone at 844-319-7588 or completing the mail order enrollment form included in the member welcome packet or available online.

Refill optionsOnce enrolled, refills can be requested by mail, phone, or online; prescribing provider may fax or call Cornerstone to initiate prescriptions (fax: 781-805-8221).

DME/Prosthetics/Orthotics manager

ManagerNorthwood, Inc. manages most durable medical equipment, prosthetics, orthotics and medical supplies for the plan.

AccessMembers should contact Member Service at 855-833-8122, visit wellsense.org, or call their PCP for help finding network DME/prosthetics/orthotics providers.

Coverage rulesDME must be prescribed by a network physician, purchased/rented from a network provider, and the plan decides rent vs buy and covers the least costly adequate item (one item per type).

Table of Contents entries

Included entriesTable of Contents lists major chapters and services such as Inpatient Services, Outpatient Services, Prescription Drug Exception Requests, and Exclusions from Covered Services.

Page rangeTOC entries in this excerpt reference pages approximately 19–72 for Chapters 3–8 and related sections.

UseRefer to the TOC to find chapter headings and navigate to detailed coverage rules or administrative provisions.

Table of Contents

PurposeTable of Contents: an index of chapters and topics with page references to help locate sections of the EOC.

ExamplesShows CHAPTER 3: Covered Services (p.19), CHAPTER 4: Eligibility/Enrollment (p.47), CHAPTER 5: Member Satisfaction (p.51), CHAPTER 6–8 and Notices/Privacy Practices (p.59–72).

Navigation tipUse TOC page numbers to jump to specific chapters such as Prescription Drug Exception Requests (p.37) or Exclusions (p.42).

Special protections (privacy)

Special protections notedTOC highlights a 'Special Protections' section addressing additional privacy protections for HIV, alcohol and substance use disorders, mental health, and genetic information.

LocationSpecial Protections referenced in Table of Contents and Privacy Practices sections (see page references around 70–72).

ImplicationThese protections indicate restricted uses/disclosures and opt-out/notification requirements for sensitive PHI categories.

Table of Contents / Chapter headings

TOC / Chapter headingsTable of Contents lists major chapters (e.g., CHAPTER 3: COVERED SERVICES; CHAPTER 4: ELIGIBILITY; CHAPTER 7: PLAN ADMINISTRATION) and subheadings for administrative topics and privacy notices.

Privacy noticesReferences to Notice of Privacy Practices and PHI uses/disclosures appear in the TOC (pages ~70–72).

Fraud reportingCHAPTER 8 'Your Responsibility to Report Fraud' is listed in the TOC (p.68).

Deductible

DefinitionDeductible: amount paid for certain covered services in a calendar year before the plan pays; individual and family rules apply and family contributions cap at the individual deductible amount.

Year periodDeductibles are calculated per calendar year (Jan 1–Dec 31); amounts paid prior to the start of a calendar year do not count toward the new year's deductible.

ReferSee Schedule of Benefits for your plan's specific deductible amounts.

Rx Deductible

DefinitionRx Deductible: a possible separate prescription drug deductible that must be met for certain covered prescription drugs before the plan pays; individual and family Rx deductible rules mirror medical deductible rules.

ImpactOnce Rx deductible met, member pays applicable copayment or coinsurance for covered drugs for remainder of calendar year.

SeeRefer to Schedule of Benefits for Rx deductible amounts and which drugs apply.

Copayment

DefinitionCopayment: a fixed amount you must pay for certain covered services, typically at the time of service.

TimingCopayments paid prior to the start of a calendar year are not counted toward that year's out-of-pocket maximum or deductibles.

ReferSee Schedule of Benefits for specific copayment amounts by service.

Coinsurance

DefinitionCoinsurance: the percentage of the plan's allowed amount a member pays for certain covered services on the date of service.

CalculationCoinsurance may be calculated differently for certain nonnetwork providers as required by state or federal law; see Appendix A for allowed amount definition.

Yearly resetCoinsurance payments prior to a new calendar year do not count toward the new year's out-of-pocket maximum.

Out-of-Pocket Maximum

DefinitionOut-of-Pocket Maximum: the maximum amount of cost-sharing (deductibles, copayments, coinsurance) a member must pay in a calendar year for most covered services.

ExclusionsDoes not include premiums, amounts over allowed amounts for nonnetwork providers, or costs for noncovered services.

Family ruleFamily contributions count toward family MOOP but an individual's contribution is capped at the individual MOOP amount.

Calendar Year

DefinitionCalendar Year: January 1 through December 31; deductibles, coinsurance, and out-of-pocket maximums are calculated during this period.

Proration noteIf coverage effective date creates a short first calendar year, deductibles and out-of-pocket amounts may be prorated and member will be notified.

ResetAccumulations reset at the start of each calendar year.

Emergency

DefinitionEmergency: health care services for a sudden onset medical condition that a prudent layperson would reasonably expect could result in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.

No prior authEmergency services in an ER are always covered without prior authorization or PCP referral; go to nearest emergency facility or call 911.

Post-stabilizationPost-stabilization services are covered until treating physician determines transfer or discharge is appropriate.

PCP

PCP rolePCP is the chosen network clinician who provides routine, nonroutine, and preventive care and coordinates referrals; members must obtain primary care from their designated PCP.

Selection and changesMembers may select any available PCP; family members may choose different PCPs; PCP or covering providers are available 24/7.

AssignmentIf no PCP selected within 15 days of effective date, plan may assign one based on zip code and records.

Emergency (prudent layperson standard)

Prudent layperson standardAn emergency is defined by a prudent layperson standard: sudden onset symptoms of sufficient severity that lack of immediate attention could cause serious jeopardy, impairment, or dysfunction.

GuidanceMembers should seek care at the nearest emergency facility or call 911; cost-sharing rules and inpatient admission exceptions apply as described in EOC.

Post-ER actionsIf treated in ER and not admitted, member or representative should call PCP for follow-up; if admitted to non-network inpatient after ER, notify plan within 2 working days.

Urgent care (outside service area)

Urgent care outside service areaUrgent care is medically necessary care to prevent serious deterioration when outside the service area for an unforeseen illness or injury; plan pays for medically necessary urgent care from nonnetwork providers when outside the service area.

Member actionMembers are recommended to call their PCP for guidance when appropriate but are not required to do so; applicable cost-sharing applies.

ExclusionsForeseeable care, elective admissions, routine/preventive care, and some maternity care beyond 37 weeks are not covered outside the service area.

Inpatient Hospital Care

ScopeInpatient Hospital Care: acute hospital inpatient care is covered for as many days as medically necessary and includes semi-private room and board, anesthesia, chemo/radiation, physician visits, diagnostics, dialysis, ICU/cardiac care, therapies, medications, nursing care, and surgery.

Private roomPrivate room covered only when medically necessary.

ReferSee Schedule of Benefits for any applicable cost-sharing for inpatient services.

Human Organ Transplants

Transplant coverageHuman organ transplants (bone marrow, solid organs, hematopoietic stem cell) are covered when member meets plan criteria and is approved by transplant facility and plan-authorized reviewer; must be at a network transplant facility.

Related costsPlan may cover donor-related charges to extent not covered by donor's plan and may pay medically necessary transportation for member when transplant facility is out of service area.

Approval requirementTransplant services require facility approval and plan authorization prior to coverage.

Durable Medical Equipment (DME)

DME definitionDurable Medical Equipment (DME) are devices of durable nature meeting criteria (repeated use, medical purpose, home use, necessary for daily living) and must be prescribed by a network physician.

Coverage rulesPlan covers least costly adequate DME, decides rent vs buy, requires purchase/rental from network provider, and limits coverage to one item of each type (no backups).

ExamplesExamples include crutches, canes, walkers, wheelchairs, respiratory/oxygen equipment, insulin pumps and supplies, home blood glucose monitors, hospital beds, certain braces, non-foot orthotics, and breast pumps.

Post-stabilization services

Post-stabilization definitionPost-stabilization services are covered services needed to stabilize a member's condition following an emergency until treating physician determines transfer or discharge is appropriate.

Coverage notePost-stabilization and emergency services are covered without prior authorization; plan covers ER boarding in NH acute care hospitals up to 21 days while awaiting discharge.

Member actionIf admitted to a non-network facility after ER, member or representative must notify the plan within 2 working days to allow care management and transfer arrangements.

Terminally ill

DefinitionTerminally ill: having a life expectancy of six months or less as certified by a network physician.

ContextDefinition used for hospice eligibility determinations and related coverage rules.

Plan requirementMember and physician must agree to a comfort-focused plan of care for hospice services to be covered.

Homebound

DefinitionHomebound: member's medical condition normally prevents leaving home or leaving requires substantial effort.

UseUsed to determine eligibility for home health care benefits which require a PCP-ordered home health care plan and defined medical goals.

Covered servicesWhen homebound and eligible, plan covers part-time skilled nursing, PT/OT/SLP as medically necessary components, home health aide, medical social work, nutritional consult, home infusion, and TPN.

Medical formulas

DefinitionMedical formulas: non-prescription enteral formulas ordered by a physician for home use for persons with inherited amino/organic acid disorders or impaired nutrient absorption, covered to extent required by NH law.

ConditionsMust be ordered by a physician and used for specified clinical conditions to qualify for coverage.

ReferenceSee Medical Formulas section for details and limitations.

Formulary / Conditions of Coverage

Formulary definitionFormulary: a list of prescription drugs indicating coverage, cost sharing, and any limitations or restrictions; updates posted online and members notified of changes when applicable.

Conditions of coverageCoverage requires prescription legality, provider licensure, filling at a network pharmacy (with exceptions), medical necessity, and compliance with pharmacy program rules.

Exception processPhysician may request formulary exceptions with patient-specific clinical history; approved exceptions are treated under applicable tiers and cost-sharing.

Prior Authorization

DefinitionPrior Authorization: plan-required approval by a plan authorized reviewer before certain services or drugs will be covered.

ApplicabilityApplies to a range of services (see examples in EOC) and to certain prescription drugs (expensive, brand when generic exists, new-to-market).

ConsequenceServices or drugs requiring prior authorization but not approved will not be covered by the plan.

Exception Request

DefinitionException Request: process by which a physician requests coverage for a non-formulary or restricted drug using patient-specific clinical history; plan will consider medical necessity and may grant an exception.

OutcomeApproved exceptions are covered and assigned to program tiers with corresponding cost-sharing; guidance provided for reimbursement if member paid up-front.

ContactCall Member Service for exception request details and submission instructions.

Telemedicine

DefinitionTelemedicine: virtual visit services including synchronous audio/video, asynchronous image/video, and other state/federal-authorized methods.

ParityCost sharing for telemedicine shall not exceed the cost share for the same services delivered in-person; subject to same deductible and out-of-pocket maximums.

Prior authPrior authorization may apply to some telemedicine services; plan will not deny services solely because provided via telemedicine.

services (Exclusions)

Definition'Services' in Exclusions: includes services, treatments, procedures, tests, devices, supplies, equipment, or medications when referenced in the Exclusions section.

ImplicationWhen an item is listed as excluded, it refers broadly to any of those categories unless an exception is explicitly stated.

ReferenceSee Exclusions from Covered Services section for the full list of excluded items and conditions.

Preventive eye exams

DefinitionPreventive eye exams: periodic eye and vision examinations when the member has no obvious signs or symptoms of disease or vision loss; pediatric preventive exams covered to benefit limits.

Pediatric benefitPediatric vision services cover one pair of eyeglasses or contact lenses per calendar year until end of month member turns 19, plus preventive exams up to benefit limit.

Adult routine examsRoutine adult eye exams are not covered except when medically necessary.

Policy Summary

Payerwellsense_health_plan

PolicyWellSense Clarity New Hampshire Evidence of Coverage

Policy CodePolicy 1-855-833-8122

Change TypeNo material changes

Effective DateJan 1, 2025

Next Review Date

Key ActionCall Member Service at 855-833-8122 to check the status of a utilization review or to request estimated allowed amounts and cost sharing for proposed medically necessary services.

SourceLink

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Covered Services, Limits, and Conditions

inv-01: Enrollment, network use, renewability, and access

Enrollment, network use, renewability, and access

Members must meet ACA, New Hampshire Insurance Department, CMS, and plan eligibility requirements and enroll by submitting a signed application and paying applicable premiums.

In exchange for premium payment, WellSense agrees to provide the coverage described in the EOC for the premium period.

Members must choose and receive primary care from a network Primary Care Provider (PCP); PCP manages care and arranges referrals as needed.

Non-network care requires PCP or plan prior authorization when used because no network provider has required expertise; when authorized, cost-sharing remains at network levels.

Premium rates may change annually but rates are guaranteed for a rating period of at least 12 months.

inv-03: Coverage criteria and limits (summary)

Members must consult their Schedule of Benefits to determine covered services, deductible, copayments, coinsurance, out-of-pocket maximums, and provider network for their benefit package.

Deductible and Rx deductible rules apply as described in the Schedule of Benefits; family and individual rules govern counting toward deductibles and out-of-pocket maximums.

inv-04: COVERAGE CRITERIA

Coverage rules for network vs non-network care and emergency services.

inv-05: Basic requirements and inpatient coverage

Conditions that must be met for services to be covered and description of inpatient services covered.

Services should be provided by network providers except as described in Chapter 2; lack of required prior authorization for services that need it will result in noncoverage.

Certain inpatient covered services require prior authorization by a plan authorized reviewer; providers must obtain authorization or the plan will not cover the service.

inv-06: Inpatient Hospital Care

Inpatient hospital care is covered when medically necessary and includes the following services and limits.

Room and board: semi‑private room and board covered; private room covered only when medically necessary.

inv-07: Bariatric Surgery

Bariatric surgery coverage conditions.

Member must be at least 18 years of age for bariatric surgery coverage.

inv-08: Reconstructive Surgery and Procedures

Reconstructive surgery coverage and limits.

Cosmetic procedures are excluded except as expressly stated (post‑mastectomy coverage described above).

inv-09: Human Organ Transplants

Transplant coverage and exclusions.

The plan covers donor search costs through established registries and certain donor charges incurred in donating to a member to the extent not covered by the donor's plan.

Experimental or investigational organ transplants are excluded; donor charges for members donating to nonmembers are excluded.

inv-10: Maternity Care

Maternity and newborn coverage details.

Routine nursery charges and well newborn care are covered up to 31 days after birth; newborn must be enrolled within 60 days to continue coverage beyond 31 days.

No coverage for delivery or pregnancy problems outside the service area after 37 weeks of pregnancy or when provider indicates risk for early delivery.

inv-11: Inpatient Physician and Extended Care

Inpatient professional services and extended care.

Inpatient physician and surgical services (physicians, surgeons, assistant surgeons, anesthesiologists) are covered as part of inpatient stay; cost‑sharing listed in Schedule of Benefits.

If no extended care bed available, plan may arrange for hospital to provide extended care services until bed available; those extra hospital days count toward extended care limits.

inv-12: Outpatient Services

Outpatient authorization requirement.

Certain outpatient covered services require prior authorization by a plan authorized reviewer; if provider does not obtain authorization, the plan will not cover the service.

Providers and members can call Member Service to check prior authorization status and request approvals; prior authorization determinations are made within legally set timeframes.

inv-13: Abortion

Abortion coverage exceptions.

Termination of pregnancy is covered when the life of the mother is endangered or when the pregnancy is the result of rape or incest.

inv-14: Allergy Services

Allergy services coverage and limits.

Allergy treatment and testing are covered, including allergy injections.

Sensitivity tests are limited to one per calendar year; blood and pulmonary function tests limited to three per calendar year.

inv-15: Ambulance Services

Ambulance services coverage and exclusions.

Excluded: transport by taxi or public transportation and transport to/from medical appointments generally excluded except as described.

inv-16: Autism Spectrum Disorder Services

Autism spectrum disorder services.

inv-17: Breast Examinations

Breast examination coverage.

inv-18: Cardiac Rehabilitation

Cardiac rehabilitation coverage and exclusions.

Cardiac rehabilitation services (exercise, education, counseling) and intensive cardiac rehabilitation programs are covered when medically necessary.

Excluded: fitness/health club fees, maintenance phases that maintain rehabilitated cardiovascular health, and exercise equipment.

inv-19: Chemotherapy and Radiation Therapy

Cancer therapy coverage.

Outpatient chemotherapy and radiation therapy are covered when medically necessary.

inv-20: Chemotherapy and Radiation Therapy (outpatient oncology services)

Outpatient oncology services

Outpatient chemotherapy and radiation therapy are covered.

inv-21: Chiropractic Care

Chiropractic care limit

Chiropractic coverage for musculoskeletal adjustments and spinal manipulations up to 12 visits per calendar year when furnished by a licensed chiropractor.

inv-22: Clinical Trials

Clinical trials routine care coverage

inv-23: Dental Services

Limited dental coverage and exceptions

Most dental services are not covered; limited dental coverage applies only as described in Chapter 3.

Medically necessary dental care for accidental injury to sound natural teeth and gums is covered if treatment is sought/provided within 3 months of the injury.

Dental services necessary to prepare the mouth for medical treatments (e.g., radiation, transplants) are covered, including evaluation, x‑rays, extractions (including surgical), and anesthesia.

inv-24: Diabetes Treatment

Diabetes benefits and supply rules

Outpatient diabetes self‑management training and medical nutrition therapy covered when provided by a certified diabetes provider in‑network.

Insulin is covered with cost‑sharing per the Schedule of Benefits with a cost‑sharing cap of $30 copayment per 30‑day prescription.

inv-25: Dialysis

Dialysis coverage and exclusions

If traveling outside the service area, dialysis is covered for up to one month per calendar year with advance arrangements and prior approval obtained by the network provider.

Excluded for home dialysis: costs to get or supply power, water, or waste disposal systems; costs of a person to help with dialysis; home hemodialysis.

inv-26: Durable Medical Equipment (DME)

Durable Medical Equipment rules, covered items, and exclusions

DME must meet durability and medical necessity criteria, be prescribed by a network physician, and be purchased/rented from a network provider; plan decides whether to rent or buy.

Excluded DME includes heating pads, comfort items, foot/shoe orthotics (except for severe diabetic foot disease), exercise equipment, bed pans/rails, and equipment for sports or employment purposes.

inv-27: Early Intervention Services

Early intervention services for young children

Early intervention services covered for children through age 2 (up to 36 months) who meet established criteria; no cost sharing.

inv-28: Emergency Services

Emergency services coverage and member/provider notification

inv-29: Emergency services and post-emergency rules

Emergency services coverage and member responsibilities

Emergency room care is always covered; no prior authorization or PCP referral required; go to nearest emergency facility or call 911.

Post‑stabilization services are covered until treated and stabilized for transfer or discharge.

Emergency room boarding in an acute care hospital in NH is covered for up to 21 calendar days or until discharge, whichever is sooner.

For non‑network inpatient admission after ER, member or representative must call the plan within 2 working days; provider notice counts as satisfying requirement.

inv-30: Family planning and infertility

Family planning coverage and exclusions

Infertility interventions such as IVF, IUI, AI and services to promote conception are not covered; diagnostic and treatment for underlying causes may be covered per policy.

inv-31: Home health care

Home health care coverage and limits

Home health care covered when member is homebound for medical reasons, PCP orders a home health care plan including part‑time skilled nursing, and a defined medical goal is set by the PCP.

Excluded: custodial care, housekeeping, household repairs, meals, respite care, private duty nursing, personal care attendants, and homemakers.

inv-32: Hearing aids and examinations

Hearing and audiology

Audiology examinations and evaluations covered when performed by a PCP or network hearing specialist.

inv-33: Hospice services

Hospice coverage

Related benefits: DME and prescription drugs are covered under their respective benefits.

inv-34: Maternity services-outpatient

Maternity outpatient services

inv-35: Laboratory, radiology, and outpatient diagnostics

Laboratory and diagnostic imaging

Prior authorization is required for advanced imaging: CT/CTA, MRI/MRA, PET scans, and nuclear cardiac imaging (NCI/NPI).

Histocompatibility testing necessary to establish bone marrow donor suitability is covered per state guidelines.

inv-36: Miscellaneous covered items

Additional covered services and supplies

Long‑term antibiotic therapy for Tick‑Borne Illness is covered when medically necessary and ordered by a licensed physician after evaluation.

Low‑protein foods are covered when ordered by a physician and medically necessary for inherited amino/organic acid disorders.

Medical formulas (non‑prescription enteral formulas) are covered to the extent required by New Hampshire law for specified metabolic and absorption disorders when ordered by a physician.

inv-37: Medical formulas

Medical formulas are covered to the extent required by New Hampshire law when ordered and used for specified conditions.

Non‑prescription enteral formulas for home use are covered when ordered by a physician for persons with inherited diseases of amino acids and organic acids.

Enteral formulas for impaired nutrient absorption due to GI disorders (absorptive surface, functional length, or motility) are covered when ordered by a physician.

inv-38: Medical supplies

Medical supplies are covered when obtained from network providers; members should confirm coverage and whether items fall under prescription drug benefit.

Covered medical supplies include ostomy, tracheostomy, catheter, oxygen supplies, and supplies for insulin pumps when obtained from a network provider.

Members should call Member Service to confirm whether a particular supply is covered and whether it is covered under the prescription drug benefit.

inv-39: Mental health and substance use disorder services

Mental health and substance use disorder services are covered medically necessary inpatient, intermediate, and outpatient; managed by Carelon Behavioral Health.

inv-40: Newborn and adoptive children

Newborn and adoptive child services coverage for medically necessary newborn care and certain screenings.

Newborn hearing screenings and diagnostic CMV evaluation are covered for infants who fail the final newborn hearing screening, with parental agreement to screenings.

inv-41: Nutritional counseling

Nutritional counseling is covered when furnished by registered dieticians or nutritional professionals for disease management.

inv-42: Observation services

Observation services are covered for short-term assessment up to a specified time in an acute care facility.

Observation services in an acute care facility are covered for up to 48 hours to determine if admission or discharge is appropriate.

inv-43: Oral surgery

Oral surgery coverage for medically necessary procedures addressing function or pathology.

Medically necessary oral surgery covered includes treatment of cleft lip/palate, orthognathic surgery for jaw function, tumor treatment/biopsy, and incision & drainage of soft tissue infections.

inv-44: Outpatient and related services

Outpatient services including office visits, outpatient surgery, pediatric vision, and podiatry have defined coverage rules.

Pediatric vision (≤18) covers routine and non‑routine vision services and vision hardware per the Schedule of Benefits.

Podiatry: diabetic members receive routine and non‑routine podiatry coverage; other members covered only for non‑routine medically necessary podiatry by network providers.

inv-45: Prescription drugs

Prescription drug program coverage rules, pharmacy channels, and covered drug categories.

Mail order drugs for certain maintenance medications are provided through Cornerstone Health Solutions (enrollment required); specialty and Tier 4 drugs excluded from mail order.

inv-46: Prescription Drug Coverage Criteria

Prescription drug coverage, exceptions, and program rules

Maintenance medications covered up to a 90‑day supply at network pharmacies; certain early refill rules apply to specified products (e.g., eye drop refill timing rules).

Pharmacy management programs used: Prior Authorization (for very expensive, brand when generic available, new‑to‑market drugs), Quantity Limits, Step Therapy, and Specialty Pharmacy requirements.

inv-47: Preventive Services

Preventive health services coverage

Preventive health services are covered when provided in accordance with plan medical policy and applicable laws; comprehensive listings available in the EOC or online.

Pediatric preventive schedule and screenings from birth through early childhood are covered per the listed intervals; newborn screenings included.

inv-48: Prosthetic Devices

Prosthetic devices coverage and limits

Activity‑related prosthetics covered for members under 19 who are NH residents, limited to one activity‑specific prosthetic device per plan year.

Exclusions include electronic and myoelectric artificial limbs and wigs when hair loss is due to pattern baldness or aging.

inv-49: Rehabilitation Therapies (Outpatient)

Rehabilitation and related exclusions

Excluded: vocational rehabilitation, educational services/testing, massage therapy, school‑based speech/language/hearing treatment, and sensory integrative testing.

inv-50: Second Opinions

Second opinions

inv-51: Smoking and Tobacco Cessation

Smoking and tobacco cessation

Individual and group counseling services for tobacco cessation are covered; related prescription drugs are covered under the Prescription Drug benefit.

inv-52: Speech-Language and Hearing Disorder Services

Speech-language and hearing services

Diagnosis or treatment in a school‑based setting is excluded.

inv-53: Telemedicine Virtual Visit Services

Telemedicine

Available modalities include two‑way live audio/video, asynchronous image/video, and other state/federal‑authorized methods; prior authorization may apply to some telemedicine services.

inv-54: Speech-Language and Hearing

Speech-Language and Hearing Disorder Services are covered when medically necessary and provided by network speech-language pathologists and audiologists; benefit limits per Schedule of Benefits.

Coverage for diagnosis and treatment of speech‑language and hearing disorders when medically necessary by network providers; see Schedule of Benefits for limits.

inv-55: Telemedicine

Telemedicine virtual visit services are covered with parity to in-person cost sharing; subject to same deductible and out-of-pocket limits; some telemedicine may require prior authorization.

inv-56: Temporomandibular Joint (TMJ) Disorder

TMJ disorder coverage rules.

TMJ syndrome and TMJ disorders not proven to be caused by a specific medical condition are excluded; appliances other than a mandibular orthopedic repositioning appliance (MORA) are excluded.

inv-57: Urgent Care

Urgent care coverage.

Urgent care services are covered for members inside the service area for urgent non‑life‑threatening conditions and for unexpected illness or injury outside the service area.

inv-58: Vision Services

Medically necessary vision therapy covered for specified diagnoses (accommodative insufficiency, amblyopia, convergence insufficiency, acquired esotropia prior to surgery).

Routine and preventive eye exams for adults are not covered.

inv-59: Exclusions from Covered Services

Extensive exclusions apply; services not listed as covered are excluded and many specific therapies, devices, procedures, and settings are not covered.

Services not described as covered in the EOC are excluded.

Services related to or furnished with a non‑covered service are excluded except as expressly stated.

Codes, Prior Authorization Categories, and Limits

Cornerstone Mail Order Contactmixed

844-319-7588	Cornerstone Health Solutions mail order phone contact (enrollment required)
781-805-8221	Cornerstone Health Solutions fax for prescriptions
cornerstonehealthsolutions.org/chs-mail-order-pharmacy	Cornerstone mail-order pharmacy website for enrollment and refills

Mail Order Enrollment Notemixed

Enrollment with Cornerstone Health Solutions required to use mail order; certain maintenance drugs only

None in this segmentmixed

No codes listed

Not applicablemixed

No codes listed

Not applicablemixed

No codes listed

No billing or coding listedmixed

No codes listed

Services Subject to Prior Authorization (categories)mixed

MSK	Musculoskeletal services (spine, joint, interventional pain)
High-tech imaging	CT/CTA, MRI/MRA, PET, nuclear cardiac imaging (NCI/NPI)
Genetic Testing	Genetic testing (lab management)
DME/Orthotics	Durable medical equipment and orthotics
Nonemergency transportation	Covered nonemergency transportation
Prosthetics	Prosthetic devices
Low protein food	Low protein food
Medical formulas	Medical formulas
Home health care	Home health care services
Infertility treatment	Infertility treatment

1–10 of 19

1/2

Covered DME and Diabetes Supply ExamplesmixedCovered

Crutches/Canes/Walkers	Crutches, canes, walkers (covered DME)
Wheelchairs	Wheelchairs (covered DME)
Respiratory/Oxygen Equipment	Respiratory and oxygen equipment (covered DME)
Insulin pumps	Insulin pumps and insulin pump supplies (covered DME)
Blood glucose monitors	Home use blood glucose monitors (covered DME)
Test strips and lancets	Diabetic test strips and lancets (covered supplies)
Insulin/needles/syringes	Insulin, insulin needles and syringes (covered under prescription benefit)
Continuous glucose monitors	Continuous glucose monitors and supplies (prior approval required)
Breast pumps	Breast pumps and related supplies (covered under preventive benefit)

Advanced Imaging Prior Authorization Examplesmixed

CT/CTA	CT/CTA scans (prior authorization required)
MRI/MRA	MRI/MRA scans (prior authorization required)
PET	PET scans (prior authorization required)
NCI/NPI	Nuclear cardiac imaging (NCI/NPI) (prior authorization required)

Prescription Drug CategoriesmixedCovered

HRT	Hormone replacement therapy for peri- and post-menopausal women
Contraceptives	Oral and other prescription contraceptives (birth control drugs)
Smoking cessation drugs	Drugs to stop smoking and treat tobacco addiction (prescription required)
Insulin and supplies	Insulin; insulin pens, needles, syringes; blood glucose, urine glucose and ketone monitoring strips; lancets; oral diabetes medications (with prescription)
Hypodermic syringes	Hypodermic syringes or needles when medically necessary
Compounded medications	Certain compounded medications meeting active-ingredient and coverage criteria
Maintenance medications	Maintenance medications (covered up to 90-day supply at network pharmacies)
Epinephrine auto-injectors	Epinephrine auto-injectors
Opioid antagonists	Opioid antagonist medications
Oral anti-cancer meds	Orally administered anti-cancer medications (cost-sharing may not apply to certain meds)

1–10 of 12

1/2

No billing/coding lists in this excerptmixed

Mail order process described; Tier 4 and Specialty excluded from mail order; contact Cornerstone for enrollment and refills

N/A

N/ANot applicable in this section; no numeric thresholds provided.

Document referenceSee Table of Contents for chapter and page references.

UsePlaceholder entry indicating no coding thresholds in this segment.

Document navigation

Primary TOC pages referencedTable of Contents entries reference key chapters and pages (examples: Chapters 3–8; pages cited include 19–72).

Navigation adviceUse the Table of Contents to locate sections such as Prescription Drug Exception Requests (p.37) and Exclusions from Covered Services (p.42).

Where to get updatesOnline EOC or Member Service can confirm current page references and chapter locations.

Prior authorization decision timeframe for court-ordered minor services

Decision timeframeDetermination must be made as soon as possible and no later than 48 hours after receipt of a complete request for court-ordered services for minors.

Request timingProvider, member, or representative must request prior authorization within 48 hours of the effective date of the court-ordered service, placement, or program.

DME quantity limit

Quantity limitOne item of each type of DME that meets the member's needs; no backup or duplicate items are covered.

Repair and maintenanceRepair and maintenance of covered DME are included under the benefit.

Hearing aid quantity

Hearing aid quantityCoverage provided for one hearing aid for each hearing-impaired ear, as required by New Hampshire law.

Included servicesCoverage includes initial evaluation, fitting, adjustments, and related supplies such as ear molds (batteries and cleaning fluid not covered).

Provider requirementServices must be prescribed/prescribed by a licensed audiologist or hearing instrument specialist.

Maintenance medication supply limit

Maintenance medication supply limitMaintenance medications are covered up to a 90-day supply at network pharmacies.

Where to fillMaintenance medications should be filled at network pharmacies; mail-order options available for certain maintenance drugs (Cornerstone) with enrollment required.

Formulary/Program rulesCoverage subject to formulary, Pharmacy Programs (prior authorization, quantity limits, step therapy) and other program rules.

Early refill timing for eye drops (30-day supply)

ConditionsPrescriber must have indicated authorized refills, request must not exceed authorized refill count, and the prescription must be a covered benefit.

LimitationsPrescription must not have been refilled more than once during the 30-day period prior to the early refill request.

Early refill timing for eye drops (90-day supply)

ConditionsPrescriber must have indicated authorized refills, request must not exceed authorized refill count, and the prescription must be a covered benefit.

LimitationsPrescription must not have been refilled more than once during the 90-day period prior to the early refill request.

What Providers and Members Must Do

Documentation Required

Utilization Review Inquiry

Call Member Service to find out the status of a utilization (medical necessity) review decision.

Note

Primary Care Provider contact for routine and urgent care

For preventive, routine, non‑routine, and urgent care inside the service area, always call the member's Primary Care Provider (PCP) to obtain and coordinate care.

Documentation Required

DME/Prosthetics/Orthotics access

Contact Member Service or your PCP; the plan contracts with Northwood, Inc. to manage most durable medical equipment, prosthetics, orthotics, and related supplies.

Documentation Required

Pharmacy benefits manager contact

Contact Member Service or Express Scripts for prescription drug benefit questions; Express Scripts is the plan's pharmacy benefits manager.

Documentation Required

Mail order pharmacy enrollment and refill process

Cornerstone phone: 844-319-7588; fax: 781-805-8221
Enroll via the mail order form in the welcome packet or at cornerstonehealthsolutions.org/chs-mail-order-pharmacy

Documentation Required

Behavioral health/SUD network management

Carelon 24‑hour line: 877-957-5600
Crisis support: 988 and NH Rapid Response resources

Prior Authorization

Emergency care instructions

In an emergency, seek care at the nearest emergency facility and call 911 (or the local emergency number if 911 is unavailable).

Note

Table of Contents — no authorization details

The Table of Contents lists sections such as Prescription Drug Exception Requests and Exclusions from Covered Services but does not provide authorization rules in this excerpt.

Note

Table of Contents (partial)

Note

Table of Contents — Chapters and headings

Table of Contents entries include coverage, plan administration, privacy practices, PHI uses/disclosures, and special protections headings; no prior authorization rules are shown in this excerpt.

Note

Table of contents

This excerpt contains only the Table of Contents and does not include authorization rules or requirements.

Documentation Required

Cost/coverage estimate request

Estimates are based on available information and coverage depends on meeting all EOC rules and member eligibility on date of service.

Prior Authorization

Non-network provider prior authorization

If no network provider has the professional expertise required, the PCP or plan may arrange non‑network care but the PCP must first obtain prior authorization from a plan authorized reviewer.

If authorized, applicable cost‑sharing remains at network levels.

Prior Authorization

Prior authorization overview and contact

If authorization is not obtained, the plan will not cover the service.

Prior Authorization

Examples of services requiring prior authorization

Prior Authorization

Prior authorization timing for court-ordered services (minors)

Prior Authorization

Outpatient prior authorization requirement

Certain outpatient covered services require prior authorization by a plan authorized reviewer; services performed without required authorization will not be covered.

Prior Authorization

Dialysis prior approval for out-of-area travel

When Medicare is primary, the member must apply for Medicare; plan covers costs exceeding Medicare when applicable.

Documentation Required

Post-emergency inpatient notice requirement

Prior Authorization

Continuous glucose monitor prior approval

Prior approval is required for coverage of continuous glucose monitors and for continuous glucose monitor supplies when those supplies are covered through a contracted pharmacy.

Prior Authorization

Prior authorization for advanced imaging

Prior authorization is required for advanced imaging tests including CT/CTA, MRI/MRA, PET scans, and nuclear cardiac imaging (NCI/NPI).

Documentation Required

Post-emergency inpatient notice requirement (repeat)

Documentation Required

Home health care ordering

Covered services include part‑time skilled nursing, part‑time PT/OT/SLP when a component of skilled nursing, medical social work, nutritional consult, home health aide while receiving skilled nursing, home visits by a network physician, inhalation therapy, home infusion therapy, and TPN.

Prior Authorization

Mental health/substance use prior authorization rules

Contact Carelon at 877-957-5600 to confirm authorization requirements.

Prior Authorization

Pharmacy prior authorization

Coverage for certain prescription drugs is subject to prior authorization by a plan authorized reviewer; providers must confirm necessary plan approvals have been obtained before prescribing.

Pharmacy programs include Prior Authorization, Quantity Limits, Step Therapy, and Specialty Pharmacy requirements.

Prior Authorization

Prior Authorization for Certain Drugs

Documentation Required

Exception Request Process

If a member pays up front for a previously authorized drug, Member Service will provide instructions for reimbursement.

Prior Authorization

Telemedicine Prior Authorization Note

Prior authorization may apply to telemedicine virtual visit services; providers should verify authorization requirements for telemedicine encounters.

Prior Authorization

TMJ prior authorization

Coverage for TMJ disorder treatment may require prior authorization by a plan authorized reviewer; always check with the provider to ensure necessary plan approval has been obtained.

Prior Authorization

Telemedicine prior authorization note (repeat)

Prior authorization may apply for telemedicine virtual visit services—verify prior authorization requirements before scheduling telemedicine visits.

Key Terms and Definitions

Primary Care Provider (PCP)

Selection timingIf no PCP is selected within 15 days of coverage effective date, the plan may assign one based on zip code and other records.

AvailabilityPCPs or their covering providers are available 24 hours a day.

Evidence of Coverage (EOC)

DefinitionEvidence of Coverage (EOC): the legal contract between the member and WellSense that describes rights, obligations, covered and noncovered services, and the Schedule of Benefits.

ContentsIncludes Schedule of Benefits, cost-sharing amounts, and Definitions; italicized terms are explained in Appendix A.

GuidanceMembers are advised to read and save the EOC; use the Table of Contents to locate needed information.

Behavioral health/SUD manager

Vendor/ManagerCarelon Behavioral Health manages all mental health and substance use disorder services for the plan.

Access optionsMembers may call Carelon's 24-hour line (877-957-5600), call their PCP, go directly to a network provider, or use Carelon's website via wellsense.org.

Crisis resourcesFor immediate crisis or suicide risk, members can call/text/chat 988 or the NH Rapid Response Access Point (1-833-710-6477).

Pharmacy benefits manager

Vendor/ManagerExpress Scripts is the plan's pharmacy benefits manager responsible for administering the prescription drug benefit.

ContactMembers may contact Member Service at 855-833-8122 or contact Express Scripts directly for pharmacy benefit questions; Express Scripts customer service available 24/7.

RoleManages formulary, prior authorization, quantity limits, step therapy, and specialty pharmacy arrangements in coordination with the plan.

Mail order pharmacy contractor

ContractorCornerstone Health Solutions provides the plan's mail order pharmacy services for certain maintenance drugs; enrollment is required.

How to enrollMembers enroll by calling Cornerstone at 844-319-7588 or completing the mail order enrollment form included in the member welcome packet or available online.

Refill optionsOnce enrolled, refills can be requested by mail, phone, or online; prescribing provider may fax or call Cornerstone to initiate prescriptions (fax: 781-805-8221).

DME/Prosthetics/Orthotics manager

ManagerNorthwood, Inc. manages most durable medical equipment, prosthetics, orthotics and medical supplies for the plan.

AccessMembers should contact Member Service at 855-833-8122, visit wellsense.org, or call their PCP for help finding network DME/prosthetics/orthotics providers.

Coverage rulesDME must be prescribed by a network physician, purchased/rented from a network provider, and the plan decides rent vs buy and covers the least costly adequate item (one item per type).

Table of Contents entries

Included entriesTable of Contents lists major chapters and services such as Inpatient Services, Outpatient Services, Prescription Drug Exception Requests, and Exclusions from Covered Services.

Page rangeTOC entries in this excerpt reference pages approximately 19–72 for Chapters 3–8 and related sections.

UseRefer to the TOC to find chapter headings and navigate to detailed coverage rules or administrative provisions.

Table of Contents

PurposeTable of Contents: an index of chapters and topics with page references to help locate sections of the EOC.

ExamplesShows CHAPTER 3: Covered Services (p.19), CHAPTER 4: Eligibility/Enrollment (p.47), CHAPTER 5: Member Satisfaction (p.51), CHAPTER 6–8 and Notices/Privacy Practices (p.59–72).

Navigation tipUse TOC page numbers to jump to specific chapters such as Prescription Drug Exception Requests (p.37) or Exclusions (p.42).

Special protections (privacy)

Special protections notedTOC highlights a 'Special Protections' section addressing additional privacy protections for HIV, alcohol and substance use disorders, mental health, and genetic information.

LocationSpecial Protections referenced in Table of Contents and Privacy Practices sections (see page references around 70–72).

ImplicationThese protections indicate restricted uses/disclosures and opt-out/notification requirements for sensitive PHI categories.

Table of Contents / Chapter headings

Privacy noticesReferences to Notice of Privacy Practices and PHI uses/disclosures appear in the TOC (pages ~70–72).

Fraud reportingCHAPTER 8 'Your Responsibility to Report Fraud' is listed in the TOC (p.68).

Deductible

Year periodDeductibles are calculated per calendar year (Jan 1–Dec 31); amounts paid prior to the start of a calendar year do not count toward the new year's deductible.

ReferSee Schedule of Benefits for your plan's specific deductible amounts.

Rx Deductible

ImpactOnce Rx deductible met, member pays applicable copayment or coinsurance for covered drugs for remainder of calendar year.

SeeRefer to Schedule of Benefits for Rx deductible amounts and which drugs apply.

Copayment

DefinitionCopayment: a fixed amount you must pay for certain covered services, typically at the time of service.

TimingCopayments paid prior to the start of a calendar year are not counted toward that year's out-of-pocket maximum or deductibles.

ReferSee Schedule of Benefits for specific copayment amounts by service.

Coinsurance

DefinitionCoinsurance: the percentage of the plan's allowed amount a member pays for certain covered services on the date of service.

CalculationCoinsurance may be calculated differently for certain nonnetwork providers as required by state or federal law; see Appendix A for allowed amount definition.

Yearly resetCoinsurance payments prior to a new calendar year do not count toward the new year's out-of-pocket maximum.

Out-of-Pocket Maximum

DefinitionOut-of-Pocket Maximum: the maximum amount of cost-sharing (deductibles, copayments, coinsurance) a member must pay in a calendar year for most covered services.

ExclusionsDoes not include premiums, amounts over allowed amounts for nonnetwork providers, or costs for noncovered services.

Family ruleFamily contributions count toward family MOOP but an individual's contribution is capped at the individual MOOP amount.

Calendar Year

DefinitionCalendar Year: January 1 through December 31; deductibles, coinsurance, and out-of-pocket maximums are calculated during this period.

Proration noteIf coverage effective date creates a short first calendar year, deductibles and out-of-pocket amounts may be prorated and member will be notified.

ResetAccumulations reset at the start of each calendar year.

Emergency

No prior authEmergency services in an ER are always covered without prior authorization or PCP referral; go to nearest emergency facility or call 911.

Post-stabilizationPost-stabilization services are covered until treating physician determines transfer or discharge is appropriate.

PCP

PCP rolePCP is the chosen network clinician who provides routine, nonroutine, and preventive care and coordinates referrals; members must obtain primary care from their designated PCP.

Selection and changesMembers may select any available PCP; family members may choose different PCPs; PCP or covering providers are available 24/7.

AssignmentIf no PCP selected within 15 days of effective date, plan may assign one based on zip code and records.

Emergency (prudent layperson standard)

GuidanceMembers should seek care at the nearest emergency facility or call 911; cost-sharing rules and inpatient admission exceptions apply as described in EOC.

Post-ER actionsIf treated in ER and not admitted, member or representative should call PCP for follow-up; if admitted to non-network inpatient after ER, notify plan within 2 working days.

Urgent care (outside service area)

Member actionMembers are recommended to call their PCP for guidance when appropriate but are not required to do so; applicable cost-sharing applies.

ExclusionsForeseeable care, elective admissions, routine/preventive care, and some maternity care beyond 37 weeks are not covered outside the service area.

Inpatient Hospital Care

Private roomPrivate room covered only when medically necessary.

ReferSee Schedule of Benefits for any applicable cost-sharing for inpatient services.

Human Organ Transplants

Related costsPlan may cover donor-related charges to extent not covered by donor's plan and may pay medically necessary transportation for member when transplant facility is out of service area.

Approval requirementTransplant services require facility approval and plan authorization prior to coverage.

Durable Medical Equipment (DME)

Coverage rulesPlan covers least costly adequate DME, decides rent vs buy, requires purchase/rental from network provider, and limits coverage to one item of each type (no backups).

Post-stabilization services

Coverage notePost-stabilization and emergency services are covered without prior authorization; plan covers ER boarding in NH acute care hospitals up to 21 days while awaiting discharge.

Member actionIf admitted to a non-network facility after ER, member or representative must notify the plan within 2 working days to allow care management and transfer arrangements.

Terminally ill

DefinitionTerminally ill: having a life expectancy of six months or less as certified by a network physician.

ContextDefinition used for hospice eligibility determinations and related coverage rules.

Plan requirementMember and physician must agree to a comfort-focused plan of care for hospice services to be covered.

Homebound

DefinitionHomebound: member's medical condition normally prevents leaving home or leaving requires substantial effort.

UseUsed to determine eligibility for home health care benefits which require a PCP-ordered home health care plan and defined medical goals.

Medical formulas

ConditionsMust be ordered by a physician and used for specified clinical conditions to qualify for coverage.

ReferenceSee Medical Formulas section for details and limitations.

Formulary / Conditions of Coverage

Conditions of coverageCoverage requires prescription legality, provider licensure, filling at a network pharmacy (with exceptions), medical necessity, and compliance with pharmacy program rules.

Exception processPhysician may request formulary exceptions with patient-specific clinical history; approved exceptions are treated under applicable tiers and cost-sharing.

Prior Authorization

DefinitionPrior Authorization: plan-required approval by a plan authorized reviewer before certain services or drugs will be covered.

ApplicabilityApplies to a range of services (see examples in EOC) and to certain prescription drugs (expensive, brand when generic exists, new-to-market).

ConsequenceServices or drugs requiring prior authorization but not approved will not be covered by the plan.

Exception Request

OutcomeApproved exceptions are covered and assigned to program tiers with corresponding cost-sharing; guidance provided for reimbursement if member paid up-front.

ContactCall Member Service for exception request details and submission instructions.

Telemedicine

DefinitionTelemedicine: virtual visit services including synchronous audio/video, asynchronous image/video, and other state/federal-authorized methods.

ParityCost sharing for telemedicine shall not exceed the cost share for the same services delivered in-person; subject to same deductible and out-of-pocket maximums.

Prior authPrior authorization may apply to some telemedicine services; plan will not deny services solely because provided via telemedicine.

services (Exclusions)

Definition'Services' in Exclusions: includes services, treatments, procedures, tests, devices, supplies, equipment, or medications when referenced in the Exclusions section.

ImplicationWhen an item is listed as excluded, it refers broadly to any of those categories unless an exception is explicitly stated.

ReferenceSee Exclusions from Covered Services section for the full list of excluded items and conditions.

Preventive eye exams

DefinitionPreventive eye exams: periodic eye and vision examinations when the member has no obvious signs or symptoms of disease or vision loss; pediatric preventive exams covered to benefit limits.

Pediatric benefitPediatric vision services cover one pair of eyeglasses or contact lenses per calendar year until end of month member turns 19, plus preventive exams up to benefit limit.

Adult routine examsRoutine adult eye exams are not covered except when medically necessary.