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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. There are no out-of-network benefits, with the exception of emergency care.
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.
Fallon Health tiers specialists based on quality and/or cost efficiency. Members pay lower copays when they see Tier 1 or Tier 2 specialists. Contact the plan to see how your provider is rated.
Do your doctors and hospitals participate in Fallon Direct?
Contact the Plan.
Contact the plan for additional information on
participating providers and benefits.
Fallon Health 1.866.344.4442
$550 per individual up to a maximum of $1,100 per family.
$5,000 per individual; $10,000 per family
Primary Care Provider Office Visit
$15 per visit
Most covered at 100% - no copay
Specialist Physician Office Visit
***Tier 1 (excellent): $30 per visit
**Tier 2 (good): $60 per visit
*Tier 3 (standard) $90 per visit
Outpatient Behavioral Health and Substance Use Disorder Care
$15 per visit
Retail Clinic and Urgent Care Center
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
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:
Find a provider
M-F 8:45 a.m.-5 p.m.