Plan Overview

Limited Network Plan logo

Fallon Health Direct 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 and obtain referrals to specialists.  The plan offers a selective network based in a geographically concentracted area. 

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.

Specialist Tiering

Effective July 1, 2015, Fallon Health Direct will tier the following specialists based on quality and/or cost efficiency: Allergists/Immunologists, Cardiologists, Endocrinologists, Gastroenterologists, Hematologists/ Oncologists, Nephrologists, Neurologists, Obstetricians/Gynecologists, Orthopedists, Otolaryngologists (ENTs), Podiatrists, Pulmonologists, Rheumatologists, and Urologists. Members will pay lower copays when they see Tier 1 or Tier 2 specialists. Contact the plan to see how your provider is rated.

! Your Responsibility

Do your doctors and hospitals participate in Fallon Direct?

Contact the Plan.

Plan Contact Information

Contact the plan for additional information on
participating providers and benefits.

Fallon Health 1.866.344.4442

Calendar Year Deductible - will transition to fiscal year

$300 per individual up to a maximum of $900 per family.

In-Network Out-of-Pocket Maximum

$5,000 per individual; $10,000 per family 

Copays Effective July 1, 2015

Primary Care Provider Office Visit
$15 per visit

Preventive Services

Most covered at 100% - no copay

Specialist Physician Office Visit           

Tier 1: $30 per visit

Tier 2: $60 per visit

Tier 3: $90 per visit

Outpatient Mental Health and Substance Abuse Care

$15 per visit

Retail Clinic

$15 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):

$275 per admission

Outpatient Surgery (Maximum four copays per person per calendar year)

$250 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:   $25
Tier 2:   $30                            Tier 2:   $75
Tier 3:   $65                            Tier 3:   $165

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 Health Direct Care is available in the following Massachusetts counties:

Bristol, Essex, Middlesex, Norfolk, Plymouth, Suffolk, Worcester

Fallon Health Direct Care is available only in certain parts of  the following Massachusetts counties; contact the plan to find out if you live in the service area:

Hampden, Hampshire


Fallon Health Direct Care Schedule of Benefits Handbook FY15 doc format of FallonDirectScheduleOfBenefitsFY15.doc

Fallon Health Direct Care Schedule of Benefits Handbook FY15 pdf format of FallonDirectScheduleOfBenefitsFY15.pdf

Fallon Health Direct Care Evidence of Coverage Handbook FY15 doc format of FallonDirectEvidenceOfCoverageFY15.doc
file size 4MB

Fallon Health Direct Care Evidence of Coverage Handbook FY15 pdf format of FallonDirectEvidenceOfCoverageFY15.pdf
file size 1MB  

This information provided by the Group Insurance Commission .