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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
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: $20 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, $50 for Tier 3 (retail up to a 30-day supply)
$20 for Tier 1, $50 for Tier 2, $110 for Tier 3 (mail order up to 90-day supply)
Note:A generic preferred program is now in place. This means
that if you fill a prescription with a brand-name drug when a generic is available,
you will be responsible for the drug copayment
plus the cost of the difference between the
two drugs.
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Vision
You are covered for one routine eye examination in each 24-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 mental health copayment: Covered in full
- Inpatient substance abuse care copayment:Covered in full, up to 30 days per calendar year
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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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High-end radiology
Includes MRI, PET, and CT.
Copayment: $75 (maximum one copayment per day)
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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, Signature Healthcare Bridgewater Goddard Park Medical Associates 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
- Faulkner Hospital
- Harrington Memorial Hospital
- HealthAlliance Hospitals
- Hubbard Regional Hospital
- Lahey Clinic
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- Lawrence General Hospital
- Lowell General Hospital
- Massachusetts General Hospital*
- MetroWest Medical Center
- Milford Regional Medical Center
- Mount Auburn Hospital
- New England Baptist Hospital*
- Saint Vincent Hospital
- Signature Healthcare Brockton Hospital
- Tufts Medical Center*
- 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 $400 ($200 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 ChooseHealthy™, 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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