Frequently asked questions for members

To better serve our Fallon Health members, we have compiled some of the most frequently asked questions below.*

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On this page:

Benefits and plans

Doctor visits and provider networks

Prescription drugs

Manage your health

Benefits and plans

Question:
Do you have more than one health insurance plan? And which one do I have?

Answer:
The simplest way to tell which health plan you have is to check your member ID card. The name of your plan is on the right-hand side of this membership card, under our logo.

We offer a wide array of health insurance plans. To learn more about your particular plan, contact Fallon's Customer Service Department:

  • By phone at the number on the back of your ID card (TRS 711).

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Question:
What is the difference between a referral and a prior authorization request?

Answer:
A referral is simply a recommendation from your physician for you to see another physician or provider, typically for services outside of your provider’s scope of practice. Getting a referral is not a guarantee that Fallon will cover the service. Please note that referrals are not required for behavioral health services.

Prior authorization is approval that your physician gets in advance so that you can receive certain services or medications. If you do not get prior authorization when required, Fallon typically will not cover the service or medication.

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Question:
What’s the difference between an HRA, an FSA and an HSA?

Answer:
A health reimbursement account (HRA) is an account funded by your employer to help cover some of your out-of-pocket medical costs, such as copayments and deductibles. Often, unused funds are allowed to roll over to the next year.

A flexible spending account (FSA) is an account that you fund to pay uncovered medical, dental, optical and dependent care expenses on a pretax basis. You decide how much you want to contribute to the account, and your contributions are typically deducted from your pay before taxes. You then pay for eligible expenses with pretax dollars in the account. An FSA can help you save money on taxes by allowing you to pay for eligible expenses with pretax dollars, but your funds typically don’t roll over from year to year.

Unlike an FSA, a health savings account (HSA) is a personal health account this is owned by you - the employee - not your employer. However, it can be funded by you, your employer, or both of you. And like the FSA, funds may only be used on qualified health care expenses. HSA's can only be combined with qualified high-deductible (QHD) health plans. Unused funds can be rolled over from year to year and you can earn interest on your savings. Contributions to your account by your employer are owned by you, even if you change jobs. 

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Question:
What factors contribute to premium rates?

Answer:
Premium rates are determined by several factors and depends on if you are purchasing insurance on your own or as part of an employer group. For those purchasing on their own, premium rate factors include age of anyone on the contract (dependents), not just the subscriber, where you live, plan design, network chosen, how many people are going to be on your contract, and when you want your health insurance to start. If you are part of a large employer group, other factors like plan design, network chosen and claims history may be included in establishing the rate.

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Question: 
How can I determine how much a service will cost and if it applies toward my deductible?

Answer:
Service coverage is outlined in your Schedule of Benefits and Member Handbook.  You can review your benefits by logging on to MyFallon (our secure member portal), or by calling Customer Service at the phone number on the back of your ID card.

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Question: 
What is an out-of-pocket maximum and how does it work?

Answer:
An out-of-pocket maximum (OOPM) is the most amount of money a member will pay for specified, covered health services within a calendar year. Items (such as copayments and deductibles) that count toward your out-of-pocket max vary depending on the product and plan design, so please review your Member Handbook by logging on to MyFallon (our secure member portal) or by calling Customer Service at the phone number on the back of your ID card.

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Question:
How do I know if a service is covered and if it requires prior authorization?

Answer:
When your primary care provider or specialist suggests a treatment, they will be able to confirm if it requires authorization from us. Providers have access to any forms or phone numbers that should be used in order to get the care you need. It’s also helpful for you to know what is covered. Learn more about your benefits by logging on to MyFallon (our secure member portal) or by calling Customer Service at the phone number on the back of your ID card.

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Doctor visits and provider networks

Question: 
What is a “referral circle”?

Answer:
Some physician groups may choose to only refer you to specialists within a group of providers. Since Fallon cannot require that the provider refer you to anyone outside their “circle” for services, it’s at the provider’s discretion who they refer you to, unless there isn’t a provider available within their referral circle who specializes in the type of care you need.  

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Question:
Is my doctor on the plan?

Answer:
To check if your doctor accepts Fallon Health, check our Find a Doctor tool. This online tool lists all network providers affiliated with the plan you belong to or are considering. You can also verify this information by contacting Fallon's Customer Service Department at the number on the back of your ID card.

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Question:
How do I choose or change my primary care provider (PCP)?

Answer:
To choose or change your PCP, first check to see if the provider is in the network of the plan you belong to. You can do this by looking in our Find a Doctor tool or by calling Customer Service.

You should also confirm that the provider you want to choose is accepting new patients. Call the doctor’s office and ask if he or she is accepting new patients. It’s also a good idea to ask when the next available appointment is.

When you know which PCP you want to select, you notify us by:

  • Selecting a new PCP using MyFallon.
  • Phone at the number on the back of your member ID card.

Note: Preferred Care members are not required to designate a primary care provider.

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Question:
Where can I learn more about physicians than just their name and specialty?

Answer:
The Massachusetts Board of Registration in Medicine Physician Profile System offers a wealth of information on physicians registered to practice medicine in the Commonwealth. This includes education history, disciplinary actions, and honors and awards.

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Question:
Where can I go for urgent care?

Answer:
There are several urgent care facilities throughout Massachusetts. These include the Urgent Care Centers at Reliant Medical Group locations, ReadyMed and MinuteClinic. Learn more about where to go when you need care right away.

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Prescription drugs

Question:
What is the Fallon Health drug formulary?

Answer:
The Fallon Health formulary is a list of the drugs that we cover for our members, arranged into three or four tiers—revealing at a glance the drugs with the lowest out-of-pocket costs. Tier 1 drugs have the lowest copayments, Tier 2 drugs are in the middle, and Tier 3 and 4 drugs have the highest copayments or cost sharing. The tiers and the criteria for prior authorization are based on effectiveness and cost.

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Question:
How do I know which formulary I use?

Answer:
The formulary you use is based on what plan you are in. To find out which formulary you have, visit the Online drug formulary.

If you have a question about what formulary you should use, call our Customer Service Department at the number on the back of your ID card.

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Question:
How does Fallon determine what tier my drug is on?

Answer:
The tiers for medications are based on effectiveness and cost.

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Question:
Why do some of my medications require prior authorization?

Answer:
A number of medications are used for more than one purpose, and it’s important to be sure the best drug is used for each individual’s situation. Prior authorization helps us make that determination.

The criteria for which drugs require prior authorization is based on drug effectiveness and cost.

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Managing your health

Question:
What if I lose my membership card?

Answer:
If you lose your membership card, you can order a new one using MyFallon or request a replacement by calling Customer Service at 1-800-868-5200 (TRS 711). Please allow a minimum of two weeks to receive your new card in the mail.

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Question:
What’s the address to mail in claims for Fallon Health to pay?

Answer:
You can mail your claims to:
Fallon Health
Claims Department
PO Box 211308
Eagan, MN  55121-2908  

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Question:
Do I need to pay the bill I received from a lab/doctor/hospital?

Answer:
To see if you owe a provider payment, log in to MyFallon to look at details about your medical claims. You may owe copayments, coinsurance or an amount that would apply to your deductible. More information about what to do if you get a bill »

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Question:
My covered dependent is away at college. Is he/she covered?

Answer:
Students attending school outside the service area may not have easy access to the plan provider network. They are covered for a limited number of services while out-of-area, if authorized in advance by the plan. You must work with your PCP to get prior authorization. These services include:

  • Nonroutine medical office visits
  • Diagnostic lab and X-ray connected with a nonroutine office visits
  • Nonelective inpatient services
  • Outpatient services to diagnose and/or treat mental conditions
  • Speech therapy
  • Short-term rehabilitation services, including physical and occupational therapy are covered for up to 60 visits combined in each calendar year (combined with any in-area visits).

Aside from emergency care, the services listed above are the only services that are covered for students on an out-of-network basis. To be covered, all other services must be obtained when they return to the plan’s service area.

Services that are not covered for students while out of the plan’s service area include:

  • Routine physical, gynecological exams, vision screening and hearing screening
  • Routine preventive care
  • Non-emergency prescription medication. Students may use a network pharmacy or the prescription medication mail-order program to fill medication refills.
  • Second opinion
  • Chiropractic care services
  • Home health care
  • Outpatient surgical procedures that could be delayed until return to the plan’s service area
  • Maternity care or delivery
  • Durable medical equipment (e.g., wheelchairs), including maintenance or replacement

Preferred Care (PPO) members
Preferred Care members can utilize any provider at any hospital, but receive greater benefits by seeing a participating provider.

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Question:
Where is Fallon Health headquartered?

Answer:
1 Mercantile St., Ste 400, Worcester, MA.

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Please visit our Find a Doctor tool to determine which providers are included in your plan’s network. A paper copy can be requested by calling our Customer Service Department at the number on the back of your ID card.

* 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 the number on the back of your ID card.