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FCHP Direct Care
Below is a list of the major services that FCHP Direct Care covers. For a complete
list of benefits and coverage, please download the documents below.
Download a full, printable summary of benefits
Download the Direct Care Member Handbook (coming soon)
Office visits
FCHP Direct Care covers routine physical exams, short-term rehabilitative services,
speech therapy, prenatal and postnatal care, and chiropractic care. Limits apply to rehabilitative services and chiropractic care.
Copayment:$10 per visit for diagnostic exams. $0 per visit for
child routine physical exam and $10 per visit for adult routine physical exam.
Specialist services
FCHP Direct Care also covers office visits for a number of specialist providers
not listed above.
Copayment: $15 per visit
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Prescriptions
You are covered for any prescription medication listed on Fallon Community Health
Plan’s drug formulary that is prescribed by a plan provider for a covered
medical condition. In addition to many community pharmacies and the PharmaCare pharmacies
located in Fallon Medical Centers, you can fill prescriptions at the following major
retail chains: CVS, Brooks, Walgreens, Target, Kmart, Wal-Mart, Shaw’s and
Stop & Shop.
Visit FCHP’s
online drug formulary
FCHP’s prescription formulary is broken into three tiers, or levels, with
a different copayment for each tier.
- Tier-1 drugs are primarily generic medications and have the lowest copayment.
- Tier-2 drugs are primarily preferred brand-name medications.
- Tier-3 drugs are generally brand-name medications that have a generic or equally
effective counterpart in a lower tier.
Copayment:
$10 for Tier 1, $25 for Tier 2, $40 for Tier 3 (retail up to a 30-day supply)
$20 for Tier 1, $50 for Tier 2, $90 for Tier 3 (mail
order up to 90-day supply)
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Vision
You are covered for one routine eye examination in each 12-month period. FCHP Direct
Care members can receive eye examinations from any optometry provider in the FCHP
Direct Care network. You do not need a referral. Just call the provider of your
choice and make an appointment.
Copayment: $10 per visit
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Mental health and substance abuse
FCHP Direct care covers unlimited outpatient visits for mental health and substance
abuse counseling as well as unlimited days in a general hospital
for mental health care and unlimited days for detoxification or rehabilitation
services in an inpatient setting.
- Outpatient visits copayment: $10 per visit
- Inpatient general hospital copayment: Covered in full
- Inpatient detoxification or rehabilitation services copayment:Covered in full
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Emergency
Emergency services do not 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). All emergency
room care must be reported to the plan within 48 hours.
Copayment: $75 per visit (waived if admitted)
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Hospital
FCHP Direct Care covers unlimited days for room and board in a semiprivate room
(maximum of four copayments per year). The following is included in hospital services:
- Physicians’ and surgeons’ services
- Physical and respiratory therapy
- Intensive care services
- Prescribed
private duty nursing (when medically necessary)
- Maternity care
Copayment: $200 per admission (waived if readmitted within 30 days of discharge from an acute care)
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Physician, provider, and hospital network
In addition to hundreds of high-quality physicians contracted through Acton Medical
Associates, Charles River Medical Associates, Fallon Clinic, Lawrence General, Lowell
General, Northeast PHO and Southboro Medical
Group, FCHP Direct Care also covers care at the following hospitals:
- Addison Gilbert Hospital
- Beth Israel Deaconess Medical Center*
- Beverly Hospital
- Boston Medical Center*
- Brigham and Women's Hospital*
- Caritas Saint Elizabeth’s Medical Center*
- Children's Hospital*
- Dana-Farber Cancer Institute*
- Emerson Hospital
- Harrington Memorial Hospital
- HealthAlliance Hospitals
- Hubbard Regional Hospital
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- Lahey Clinic
- Lawrence General Hospital
- Lowell General Hospital
- Massachusetts General Hospital*
- MetroWest Medical Center
- Milford Regional Medical Center
- Mount Auburn Hospital
- New England Baptist Hospital*
- New England Medical Center*
- Saint Vincent Hospital
- UMass Memorial Medical Center - University Campus*
- UMass Memorial Medical Center - Memorial Campus*
- Winchester Hospital
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* These facilities may only be available for certain services or for specialty care
through FCHP-authorized tertiary care or our Peace of Mind Program™.
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Wellness programs
Fitness
It Fits!, FCHP’s fitness reimbursement program, gives your family
up to $300 ($150 for individual contract) to use toward a variety of healthy activities,
like a membership at local fitness centers, aerobics, Pilates and yoga classes (when
taught by a certified instructor), Weight Watchers® programs, as well as
local, town and school sports programs for all ages.
Birth and baby
FCHP’s Oh Baby! is a health and wellness program that gives parents
the information and resources they need to help take care of the “little things”
in life. Participants will receive prenatal vitamins, a book on caring for their
child, and a convertible car seat, plus a few little extras—all at no additional
cost!
Alternative health care
Our Naturally Well program offers discounts on acupuncture, chiropractic
care (in addition to any chiropractic benefit your plan may have) and massage therapy
from the American Specialty Health Networks, Inc. (ASHN) credentialed network of
qualified providers. Health and wellness products also are available at a reduced
rate through Healthyroads, an affiliate of ASHN.
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Nurse Connect health coaching
Fallon Community Health Plan has joined with Health Dialog® to give FCHP members
complimentary access to registered nurses and other health
care professionals who serve as health coaches, 24 hours a day, seven days a week,
365 days a year. When you have a health question, you can immediately contact a
health coach who can provide personal education and support, information to help
you make healthy decisions, educational materials relevant to a diagnosis or condition,
and assistance with finding additional health information online.
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Online health education and decision tools
As a member of FCHP Direct Care, you will gain access to a number of online health
education and decision tools designed to help keep you well:
- Online health coaching
- Hospital quality comparisons
- Health encyclopedias
-
Personal wellness profile
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