Plan Overview
Fallon Community Health Plan Select Care is an HMO that provides coverage through the plan’s network of doctors, hospitals, and other providers. Members must select a Primary Care Provider (PCP) to manage their care, including referrals to specialists.
Contact the plan to see if your doctors and hospitals are in the network. There are no out-of-network benefits, with the exception of emergency care.
Members pay lower copays when they see Tier 1 or Tier 2 specialists. Contact the plan to see how your provider is rated. Effective July 1, 2013, the plan will tier hospitals based on quality and/or cost; members pay a lower inpatient hospital copay when they use Tier 1 or Tier 2 hospitals. Contact the plan to find out which tier your hospital is in.
! Your Responsibility
Do your doctors and hospitals participate in Fallon Select?
Contact the plan.
Plan Contact Information
Contact the plan for additional information on
participating providers and benefits.
Fallon Community Health Plan 1.866.344.4442
Calendar Year Deductible
$250 per individual up to a maximum of $750 per family. See page __ for details.
Copays Effective July 1, 2012
Primary Care Physician Office Visit
$20 per visit.
Preventive Services
Most covered at 100% - no copay
Specialist Office Visit
Fallon Community Health Plan tiers the following specialists based on quality and/or cost-efficiency: Allergists/Immunologists, Cardiologists, Endocrinologists, Gastroenterologists, Hematologists/ Oncologists, Nephrologists, Neurologists, Obstetrician/Gynecologists, Orthopedists, Otolaryngologists (ENTs), Podiatrists, Pulmonologists, Rheumatologists, and Urologists.
***Tier 1 (excellent): $25 per visit
**Tier 2 (good): $35 per visit
*Tier 3: (standard): $45 per visit
Retail Clinic
$20 per visit
Outpatient Mental Health and Substance Abuse Care
$20 per visit
Inpatient Hospital Care – Medical (Maximum one copay per person per calendar year quarter; waived if readmitted within 30 days in the same calendar year)
***Tier 1 (excellent): $250 per admission
**Tier 2 (good): $500 per admission
*Tier 3: (standard): $750 per admission
Outpatient Surgery: (Maximum four copays per person per calendar year)
$125 per occurrence
High-Tech Imaging (e.g., MRI, PET and CT scans) (Maximum one copay per day)
$100 per scan
Emergency Room
$100 per visit (waived if admitted)
Prescription Drug
Retail up to 30-day supply: Mail Order up to 90-day supply:
Tier 1: $10 Tier 1: $20
Tier 2: $25 Tier 2: $50
Tier 3: $50 Tier 3: $110
Who is Eligible?
Employees, Retirees, GIC Retired Municipal Teachers (RMTs), Elderly Governmental Retirees (EGRs), Survivors, and their eligible dependents without Medicare are eligible.
Where You Live Determines Which Plan You May Enroll In:
Fallon Community Health Plan Select Care is available in the following Massachusetts counties:
Berkshire, Bristol, Essex, Norfolk, Franklin, Plymouth, Suffolk, Hampden, Worcester, Hampshire, Middlesex
Fallon Community Health Plan Select Care is available only in certain parts of the following state; contact the plan to find out if you live in the service area:
New Hampshire
Handbooks:
Fallon Community Health Plan SELECT Care Schedule Of Benefits Handbook FY13 
Fallon Community Health Plan SELECT Care Schedule Of Benefits Handbook FY13 
Fallon Community Health Plan Select Care Evidence Of Coverage Handbook FY13 file size 4MB
Fallon Community Health Plan Select Care Evidence Of Coverage Handbook FY13 file size 2MB
This information provided by the Group Insurance Commission.
