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.
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
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
$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
$100 per visit (waived if admitted)
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:
This information provided by the Group Insurance Commission .