Your benefits and costs

Compare the costs. Direct Care and The Advantage Plan have the same comprehensive benefits.

Members may view and download copies of their important benefit documents by going to myFallon.

  • 2020 benefits
  • 2019 benefits
Direct Care The Advantage Plan
Overview Non-tiered limited network plan, which saves you money on your health insurance premium. Offers more than 37,000 providers across Massachusetts, chosen for their medical excellence, cost-efficiency and innovation.
 Same great benefits, but with a larger tiered network of over 59,000 providers across Massachusetts. Providers are tiered based on their accessibility to the community. UMass Memorial Health Care, Saint Vincent Hospital and Reliant Medical Group can all be found in Tier 1.
Plan year deductible No deductible Tier 1:
$500 individual/
$1,500 family		 Tier 2:
$750 individual/
$2,250 family
Out-of-pocket maximum $1,000 individual
$3,000 family		 Tier 1:
$2,500 individual
$7,500 family		 Tier 2:
$3,000 individual
$9,000 family
Routine physical exams $0 per visit $0 per visit
PCP office visits $20 per visit Tier 1:
$20 per visit		 Tier 2:
$30 per visit
Specialist office visits $40 per visit Tier 1:
$40 per visit		 Tier 2:
$50 per visit
Chiropractic care
(12 visits per calendar year)		 $20 per visit $30 per visit
Urgent care/mini clinics $20 per visit $30 per visit
Telemedicine via Teladoc®– 24/7 access to a national network of U.S. Board-Certified doctors to
discuss non-emergency conditions by
phone, mobile app or online		 $20 per visit $20 per visit
Diagnostic services* (Lab, X-ray, etc.) Covered in full Covered in full after deductible
Imaging (CAT, PET, MRI scans, nuclear cardiology) (max. of one copayment per day) Covered in full $50 in a non-hospital setting
$150 in a hospital setting
Outpatient surgery 10% coinsurance Tier 1:
20% coinsurance
after deductible 		Tier 2:
40% coinsurance
after deductible
Inpatient surgery 10% coinsurance Tier 1:
20% coinsurance
after deductible 		Tier 2:
40% coinsurance
after deductible
Direct Care The Advantage Plan
Overview Non-tiered limited network plan, which saves you money on your health insurance premium. Offers more than 37,000 providers across Massachusetts, chosen for their medical excellence, cost-efficiency and innovation.
 Same great benefits, but with a larger tiered network of over 59,000 providers across Massachusetts. Providers are tiered based on their accessibility to the community. UMass Memorial Health Care, Saint Vincent Hospital and Reliant Medical Group can all be found in Tier 1.
Plan year deductible No deductible Tier 1:
$500 individual/
$1,500 family		 Tier 2:
$750 individual/
$2,250 family
Out-of-pocket maximum $1,000 individual
$3,000 family		 Tier 1:
$2,500 individual
$7,500 family		 Tier 2:
$3,000 individual
$9,000 family
Routine physical exams $0 per visit $0 per visit
PCP office visits $20 per visit Tier 1:
$20 per visit		 Tier 2:
$30 per visit
Specialist office visits $40 per visit Tier 1:
$40 per visit		 Tier 2:
$50 per visit
Chiropractic care
(12 visits per calendar year)		 $20 per visit $30 per visit
Urgent care/mini clinics $20 per visit $30 per visit
Telehealth– 24/7 access to a national network of U.S. Board-Certified doctors to
discuss non-emergency conditions by
phone, mobile app or online		 $20 per visit $20 per visit
Diagnostic services* (Lab, X-ray, etc.) Covered in full Covered in full after deductible
Imaging (CAT, PET, MRI scans, nuclear cardiology) (max. of one copayment per day) Covered in full $50 in a non-hospital setting
$150 in a hospital setting
Outpatient surgery 10% coinsurance Tier 1:
20% coinsurance
after deductible 		Tier 2:
40% coinsurance
after deductible
Inpatient surgery 10% coinsurance Tier 1:
20% coinsurance
after deductible 		Tier 2:
40% coinsurance
after deductible
It Fits! (fitness reimbursement) $250 per individual/$500 per family** to use on healthy activities like school and town sports, yoga and dance classes, new cardiovascular home fitness equipment, gym memberships at the gym of your choice, ski lift tickets and much more. **This incentive payment may be considered taxable income. Please consult your tax advisor if you have questions.



Extra services

With both The Advantage Plan and Direct Care, you get:

  • Unparalleled care management programs

  • 20% discount on more than 1,500 CVS/pharmacy brand health-related products at CVS stores nationwide and online at www.cvs.com

* Diagnostic services are tests, immunizations and services intended to diagnose, check the status of, or treat a disease or condition.

Important information

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Other information