Office visits coverage*
- The number after "PE" is your copayment for routine physicals.
- The number after "OV" is your copayment for pcp office visits.
Our plans cover office visits for both routine and diagnostic services. You may pay copayments for the services below; you also may be responsible for a deductible for certain services.
What's covered?
Service or procedure
Routine physical exams with your primary care doctor or gynecologist
Office visits to diagnose or treat an illness or an injury
Well-child visits and pediatric care
Visit to a contracted limited service clinic. Services are provided for a variety of common illnesses, including, but not limited to:
- strep throat
- ear, eyes, sinus, bladder and bronchial infection
- minor skin conditions (e.g., sun burn, cold sores)
Diagnostic lab and X-ray services, in relation to a covered office visit
Routine gynecological care services, including an annual Pap smear (cytological screening) and pelvic exam
A baseline mammogram for women age 35 to 40
A yearly mammogram for women age 40 and older
Routine eye exams, once in each 12-month period
Hearing and vision screening
Chiropractic services for acute musculoskeletal conditions.
The condition must be new or an acute exacerbation of a previous condition. Coverage is provided for up to 12 office visits in each calendar year. The actual number of visits provided is based on medical necessity as determined by your plan provider and the plan.
What isn't covered?
Service or procedure
More than one routine eye examination in each 12-month period
Fittings for contact lenses
Eyeglasses or contact lenses
Vision therapy or services (also referred to as orthoptics)
Hearing aids and the evaluation for a hearing aid
Services required by a third party or court order.
Examples are employment, school, sports, premarital and/or summer camp examinations or tests, and any immunizations required by an employer, that are related to your job and/or work conditions.
Acupuncture
Massage therapy (when not provided by an FCHP provider or physical therapist as part of your covered physical therapy benefit)
Visits to additional providers beyond a second opinion, or a second opinion with a non-plan provider
Obtaining specialty care**
When you want to visit a specialist, talk with your PCP first. He or she will help arrange specialty care for you. The following services do not require a referral when you see a provider in your plan’s network: routine obstetrics/gynecology care, screening eye exams, behavioral health services and some dental services. For more information on referral procedures for specialty services, consult your Member Handbook.
For details on your specific benefits, coverage, and copayments:
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Refer to your Member Handbook, Benefit Summary or Schedule of Benefits
or
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Call our customer service department at:
1-800-868-5200 (TDD/TTY: 1-877-608-7677), Monday through Friday, 8 a.m. to 6 p.m.
* Benefits and coverage may vary by product, plan design and employer. For specific details regarding your FCHP plan, benefits and features, please check with your employer or contact a member of our customer service team at 1-800-868-5200 (TDD/TTY: 1-877-608-7677), Monday through Friday, 8 a.m. to 6 p.m. Eastern time. MassHealth members can call FCHP Customer Service at: 1-800-341-4848 (TDD/TTY: 1-877-608-7677) Monday through Friday, 8 a.m. to 6 p.m.
** This section doesn't apply to Fallon Preferred Care PPO plan members.