How your coverage, benefits, and services work
With all of our plan designs, you get benefits and services that are meant to keep you healthy and to take care of you when you need it. The main differences between each plan are the copayments and deductibles (if your plan has them).
Most of our plans include*:
- $0 copayments for routine physicals and other preventive services
- $0 copayments for routine annual eye exams
- Office visits with your primary care physician and specialists
- Fitness reimbursements that can be used for gym memberships, home fitness equipment, and more
- Emergency room services
- Hospital care
- Mental health and substance abuse counseling
- Chiropractic care
- Member discounts on products and services to keep you healthy
You can check your Summary of Benefits, Covered Services List or your Schedule of Benefits for details on what your plan covers and what your costs are. You can also go to myFallon and log in under "View your benefits and plan documents online" for detailed information on your specific plan.
Networks and primary care providers (PCPs)
A network is a group of health care providers like doctors, hospitals and other facilities that are contracted with Fallon Health to provide covered services to you. As a Fallon member, you can choose to get your care from providers that are in your plan network.
What's my network?
You can find out which provider network you have by looking at your member ID card or your printed plan materials.
Why do I need to chose a PCP?
Your relationship with your PCP is very important because he or she will work with you and your health plan to provide or arrange most of your care. To choose a PCP in your plan network, you can use our Find a Doctor tool, or you can call Customer Service at 1-800-868-5200 (TTY users please call TRS Relay 711).
Getting specialty care
When you want to visit a specialist, talk with your PCP first. He or she will help arrange specialty care for you. Some services require prior authorization with your health plan, while some services don’t require a referral at all when you see a provider in your network.
For more information on referral procedures for specialty services, check your Summary of Benefits, Covered Services List or your Schedule of Benefits.
Emergency medical care
Emergency services don’t require referral or authorization. When you have an emergency medical condition, you should go to the nearest emergency department or call your local emergency communications system (police, fire department or 911).
For more information on emergency services, check your Summary of Benefits, Covered Services, Schedule of Benefits or visit our FAQs.
Did you receive a bill?
Log into MyFallon and click "My claims" to look at details about your medical claims to see if you owe copayments, coinsurance or an amount to apply to your deductible.
* Benefits and coverage may vary by product, plan design and employer. For specific details regarding your Fallon plan, benefits and features, please check with your employer or contact a member of our customer service team at 1-800-868-5200 (TTY users please call TRS Relay 711), Monday, Tuesday, Thursday, and Friday from 8 a.m. to 6 p.m. and Wednesday from 10 a.m. to 6 p.m. MassHealth members can call Fallon Customer Service at: 1-800-341-4848 (TTY users please call TRS Relay 711), Monday through Friday, 8 a.m. to 6 p.m.