Plan Overview

Fallon Health 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 and obtain 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. 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 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 Physician Office Visit

$20 per visit.

Preventive Services

Most covered at 100% - no copay

Specialist Office Visit

Fallon Health tiers 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. Contact the plan to see how your provider is rated.

***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:           $250 per admission
Tier 2:           $500 per admission
Tier 3:           $750 per admission

Contact the plan to see which tier your hospital is in.

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 Health Select Care is available in  the following Massachusetts counties:

Berkshire, Bristol, Essex, Franklin, Hampden, Hampshire, Middlesex, Plymouth, Suffolk, Worcester

Fallon Health 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 Health SELECT Care Schedule Of Benefits Handbook FY15 doc format of FallonSelectScheduleOfBenefitsFY15.doc

Fallon Health SELECT Care Schedule Of Benefits Handbook FY15 pdf format of FallonSelectScheduleOfBenefitsFY15.pdf

Fallon Health SELECT Care Evidence Of Coverage Handbook FY15 doc format of FallonSelectEvidenceOfCoverageFY15.doc
file size 4MB

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


This information provided by the Group Insurance Commission .