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 concentrated 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.

! 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

$250 per individual up to a maximum of $750 per family.

In-Network Out-of-Pocket Maximum

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

Copays Effective July 1, 2014

Primary Care Provider Office Visit
$15 per visit

Preventive Services

Most covered at 100% - no copay

Specialist Physician Office Visit           

$25 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):

$200 per admission

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

$110 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 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

Handbooks:

Fallon Health Direct Care Schedule of Benefits Handbook FY14 doc format of    FallonDIRECTCareSOBHandbookFY14.doc

Fallon Health Direct Care Schedule of Benefits Handbook FY14 pdf format of    FallonDIRECTCareSOBHandbookFY14.pdf

Fallon Health Direct Care Evidence of Coverage Handbook FY14 doc format of    FallonDIRECTCareEOCHandbookFY14  file size 4MB

Fallon Health Direct Care Evidence of Coverage Handbook FY14 pdf format of    FallonDIRECTCareEOCHandbookFY14.pdf

 


This information provided by the Group Insurance Commission.