Plan Overview
Fallon Community Health Plan 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, including referrals to specialists. With an HMO, you receive care through 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.
! 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 Community Health Plan 1.866.344.4442
Calendar Year Deductible
$250 per individual up to a maximum of $750 per family.
Copays Effective July 1, 2013
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 Community Health Plan Direct Care is available in the following Massachusetts counties:
Bristol, Essex, Middlesex, Norfolk, Plymouth, Suffolk, Worcester
Fallon Community Health Plan Direct Care in 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 Community Health Plan Direct Care Schedule of Benefits Handbook FY13 
Fallon Community Health Plan Direct Care Schedule of Benefits Handbook FY13 
Fallon Community Health Plan Direct Care Evidence of Coverage Handbook FY13 file size 4MB
Fallon Community Health Plan Direct Care Evidence of Coverage Handbook FY13 file size 2MB
This information provided by the Group Insurance Commission.
